oiomed 


100 

W851L 

1891 


iiosis  and  Treat,     it  of  Eye  Diseases, 


,  asev  ••# 


,  M.  D, 


MICHE    LOUTFALLAH 


THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


ypu 


A  Menstruum. 


HORSFORD'S  ACID  PHOSPHATE 


This  preparation  has  been  found  especially  serviceable  as 
a  menstruum  for  the  administration  of  such  alkaloids  as  mor- 
phine, quinine,  and  other  organic  bases  which  are  usually 
exhibited  in  acid  combination. 

The  admixture  with  pepsin  has  been  introduced  with  ad- 
vantage when  indicated. 

The  Acid  Phosphate  does  not  disarrange  the  stomach, 
but,  on  the  contrary,  promotes  in  a  marked  degree  the  process 
of  digestion. 

Dr.  R.  S.  MILES,  Glencoe,  Minn.,  says:  "I  use  it  in  a 
great  many  cases  as  a  menstruum  for  quinine,  when  an  acid  is 
necessary." 

Send  for  descriptive  circular.  Physicians  who  wish  to  test  it  will  be 
furnished  a  bottle  on  application,  without  expense,  except  express 
charges. 

Prepared  under  the  direction  of  Prof.  E.  N.  HORSFORD,  by  the 

BUMPORD  CHEMICAL  WORKS,  Providence,  R»  I. 


Beware  of  Substitutes  and  Imitations. 

CAUTION:— Be  sure  the  word  "Horaford's"  is  Printed  on  the  label. 
All  others  are  spurious.      Never  sold  in  bulk. 


« 

LEBSDNS  IN  THE  DIAGNOSIS 


AND 


TREATMENT  OF  EYE  DISEASES, 


BY 


CASEY   A.  WOOD,  C.  M.,  M.  D., 

Formerly  Clinical  Assistant,  Royal  London  Ophthalmic  Hospital 

(Moorfields};  Microscopist  and  Pathologist  to  the  Illinois  Eye 

and  Ear  Infirmary;  Professor  of  Ophthalmology,  Post 

Graduate  Medical  School;    Oculist  and  Aurist 

to  the  Alexian  Bros.  Hospital,   Chicago. 


WITH  NUMEROUS  WOOD-CUTS. 


1891. 
GEORGE    S.  DAVIS, 

DBTROIT,    MICH. 


Copyrighted  by 

GEORGE  S.  DAVIS. 

1891. 


To  my  friends, 

WM.  LANG,  F.  R.  C.  S., 
Surgeon  Royal  London  Ophthalmic  Hospital, 


.  DR.  W.  UHTHOFF, 

Professor  of  Ophthalmology  in  the 

University  of  Marburg. 


TABLE  OF  CONTENTS. 


Preface xi 

LESSON  I. 

THE   NORMAL  EYE. 

PAGlL 

Introductory — A  Plea  for  the  General  Study  of  Ocular 
Diseases — Some  Simple  Methods  of  Examining  the 
Eye — Inspection  of  the  Normal  Eye  as  a  Preliminary 
to  Pathological  Studies — Appearance  of  Healthy  Eye- 
lids, Conjunctiva,  Sclera  and  Cornea — The  Pupil,  the 
Iris,  and  the  Lens — Normal  Tension — Focal  Illumi- 
nation— Exploring  the  Orbit — The  Superficial  Blood- 
vessels of  the  Eye — Testing  the  Visual  Acuity  and 
Muscular  Power — Color  Perception — Hints  about 
Examining  the  Eyes  of  Children I 

LESSON  II. 

THE   EYE   IN    DISEASE. 

Examination  of  the  Patient — The  History  of  the  Case — 
Signs  and  Symptoms — The  Visual  Acuity — Everting 
the  Lids — The  Bifocal  Illumination — The  Examina- 
tion by  Reflected  Light — Some  Points  in  Diagnosis — 
Abnormal  Tension  and  Lacrymation — The  Ocular 
Blood  Supply  in  Disease — Remedies  Commonly 
Used  in  Ophthalmic  Practice — Leeches,  Natural  and 
Artificial — Heat  and  Cold — Blisters — Atropine,  Ho- 
matropine,  and  Duboisine — Eserine  and  Pilocar- 
pine — Cocaine — Boracic  Acid  and  Nitrate  of  Silver — 
Other  Remedies — Bandages  and  Shades — Goggles 
and  Colored  Glasses — Eye  Cups  and  Eye  Droppers — 
Irrigation  of  the  Eye — The  Cautery — Preparing  for 
Operations — Antiseptic  Precautions — A  Clean  Sur- 
geon, Clean  Instruments,  and  a  Clean  Patient 16 


VIII 

LESSON  III.  PAGE. 

DISEASES    OF    THE   EYELIDS   AND    CONJUNCTIVA. 

Atropine  Irritation  —  Pterygium  —  Pinguecula —  Lithia- 
sis — Blepharitis — A  "Black  Eye" — Herpes  of  the 
Lid — Stye,  or  Hordeolum — Chalazion,  or  Cyst  of  the 
Eyelid  —  Lupus  and  Epithelioma — Xanthelasma — 
Entropion  and  Ectropium — Surgical  and  Other  Treat- 
ment of  These  Conditions — Hotz's  Operation — Pto- 
sis — Lagophthalmos — Symblepharon 32 

LESSON  IV. 

DISEASES  OF  THE  LACHRYMAL  APPARATUS. 
Epiphora — Lacrymation — Dacryocystitis-Lachrymal  Ab- 
scess— Slitting  Up  the  Canaliculus — Passing  the  Na- 
sal Probe — Treatment  of  Lachrymal  Obstruction  by 
the  Syringe  of  Meyer  or  Anel 49 

LESSON   V. 

DISEASES  OF  THE  CORNEA  AND  SCLEROTIC. 
Arcus  Senilis—  Keratitis — Phlyctenular  Keratitis — For- 
eign Bodies  in  the  Cornea — Interstitial  Keratitis — 
Punctate  keratitis — Ulcers  of  the  Cornea — Spreading 
and  Non-spreading  Ulcers — Hypopyon  and  Onyx — 
Paracentesis  of  the  Anterior  Chamber — Leucoma  Ad- 
herens — The  Use  of  the  Cautery — Senile  Ulcer — Opa- 
cities of  the  Cornea — Nebula,  Macula,  and  Leucoma — 
Staphyloma  Anterius — Tatooing  the  Cornea — Scler- 
itis  and  Epi-scleritis 56 

LESSON  VI. 

DISEASES    OF   THE   IRIS   AND   ANOMALIES   OF  THE   PUPIL. 

Coloboma  of  the  Iris — Differences  in  Color — Albinism  — 
Nystagmus — Iridodialysis — Various  Kinds  of  Iritis — 


IX 

PAGE. 

Iridectomy  —  Variations  in  the  Size  of  the  Pupil — 
Myosis  and  Mydriasis — Various  Conditions  which 
Produce  Anomalies  of  the  Pupil — Hippus 79 

LESSON   VII. 

CATARACT  AND  OTHER  AFFECTIONS  OF  THE  CRYSTALLINE  LENS. 

Dislocation  of  the  Lens — Iridodonesis — Aphakia,  or  Ab- 
sence of  the  Lens — Cataract — Nuclear  and  Cortical 
Cataract — Senile  Cataract — The  Operation  for  Re- 
moval— When  to  Operate — After-treatment — Com- 
plications— Soft  Cataract — The  Zonular  or  Lamellar 
Cataract  of  Children — Discission  or  Needling 97 

LESSON  VIII. 

GLAUCOMA. 

The  Necessity  of  an  Early  Diagnosis  —  Varieties  — 
Causes — Intraocular  Changes  in  the  Disease — Signs 
and  Symptoms — Treatment — Iridectomy  and  Scler- 
otomy — Eserine 112 

LESSON  IX. 

OCULAR  AFFECTIONS   IN   GENERAL    DISEASES. 

Manifestations  of  Syphilis,  Rheumatism,  and  Other  Dia- 
theses— Muscat  Volitantes — Amblyopia — Toxic  Am- 
blyopia — Eye  Symptoms  in  Tobacco  and  Alcohol 
Poisoning — Abscess  of  the  Orbit — Graves'  Disease — 
Progressive  Locomotor  Ataxia  —  Diphtheria  — 
Bright's  Disease — Migraine — Malaria — Reflex  Neur- 
oses —  Sympathetic  Ophthalmia  —  Penetrating 
Wounds  of  the  Globe — Sympathetic  Irritation  and 
Inflammation — Treatment — Enucleation  of  the  Eye- 
ball   117 


LESSON  X.  PAGE. 

PARALYSIS,    SQUINT,    AND    OTHER   MUSCULAR    TROUBLES. 

The  Physiology  of  the  Subject — The  Nerve  Supply — 
Ocular  Paralyses — Their  Symptoms — Paralysis  of 
the  Sixth  Nerve — Paralysis  of  the  Fourth  Nerve — 
Oculo-motor  Paralysis — Ophthalmoplegia — Causes 
and  Treatment  of  Paralysis — Strabismus  or  Squint — 
Convergent  and  Divergent  Squint — The  Measure- 
ment of  Squint — Treatment — Operations  for  Strabis- 
mus— Tenotomy — Advancement 134 

INDEX 147 


PREFACE. 


The  purpose  of  this  manual  is  to  aid  the  physician  to 
detect  and  treat,  by  means  always  at  hand,  those  diseases  o*f 
the  eye  which  experience  has  shown  are  most  frequently 
overlooked  in  the  course  of  general  practice.  Ocular  dis- 
eases which  are  commonly  and  easily  diagnosed  by  the  non- 
specialist  are  not  so  much  dwelt  upon  as  those  that  are  more 
obscure;  while  two  subjects  of  great  general  importance, 
already  fully  and  ably  discussed  in  this  Series, — Conjuncti- 
val  Diseases,  by  Prof.  Mittendorf,  and  the  Determination  of 
the  Necessity  for  Wearing  Glasses,  by  Prof.  St.  John  Roosa — 
although  partly  falling  within  the  scope  of  such  a  treatise  as 
this,  will  be  passed  over.  A  perusal  of  these  monographs 
would  be  necessary  to  complete  the  programme  just  laid 
down. 

Frequent  references,  for  the  student's  benefit,  will  be  made 
not  only  to  the  pages  of  this  but  to  those  of  the  other  works 
on  the  eye  published  in  the  Series.  To  save  space,  these 
references  will  be  made  by  bracketed  page  and  initial  only. 
For  example,  (27)  means  page  27  of  this  book  ;  (R.  34)  will 
refer  to  page  34  of  Prof.  Roosa's  work  on  the  Determination 
of  the  Necessity  for  Wearing  Glasses  ;  (M.  40)  is  intended  to 
indicate  page  40  of  Prof.  Mittendorf's  monograph  on  Granu- 
lar Lids  and  Contagious  Ophthalmia  ;  while  (C.  22)  means 
page  22  of  Dr.  Claiborne's  book  on  the  Theory  and  Practice 
of  the  Ophthalmoscope  Of  course,  this  manual  makes  no 
pretension  to  being  a  complete  treatise  upon  the  subjects  of  its 
chapter  headings.  The  writer  trusts,  however,  that  the  space 
at  his  disposal  has  been  filled  with  such  practical  hints  and 
useful  information  as  will  be  most  likely  to  assist  the  non- 
specialist  practitioner. 

204  Dearborn  St.,  Chicago. 


LESSON  I. 

THE  NORMAL  EYE. 

Introductory — A  Plea  for  the  General  Study  of  Ocular  Dis- 
eases— Some  Simple  Methods  of  Examining  the  Eye — 
Inspection  of  the  Normal  Eye  as  a  Preliminary  to 
Pathological  Studies— Appearance  of  Healthy  Eyelids, 
Conjunctiva,  Sclera,  and  Cornea — The  Pupil,  the  Iris, 
and  the  Lens — Normal  Tension — Focal  Illumination — 
Exploring  the  Orbit — The  Superficial  Blood-vessels  of 
the  Eye — Testing  the  Visual  Acuity  and  Muscular 
Power — Color  Perception — Hints  about  Examining  the 
the  Eyes  of  Children. 

The  conduct  of  the  busy  practitioner  towards 
such  ocular  affections  as  occur  in  his  practice  usually 
differs  from  his  treatment  of  most  other  diseases. 
The  acquirement  of  even  a  moderate  degree  of 
knowledge  respecting  diseases  of  the  eye — especially 
those  requiring  the  use  of  the  ophthalmoscope — 
necessitates  considerable  study  and  frequent  chances 
for  observation.  The  every-day  routine  of  practice 
affords  neither  opportunities  for  the  one  nor  time  for 
the  other,  and  it  is  not,  therefore,  surprising  that  such 
cases  are  usually  referred  to  a  confrere  who  makes  a 
special  study  of  them. 

While  one  must  admit  the  advantages  that,  on 
the  whole,  accrue  to  both  patient  and  medical  man 
from  such  a  disposition  of  this  class  of  maladies,  it  is 
not  without  its  drawbacks. 

There   is   a   fairly   well-defined    and    important 


group  of  diseases,  affecting  various  parts  of  the  visual 
apparatus,  whose  signs  and  symptoms  are  especially 
prone  to  be  overlooked  or  misinterpreted  by  the  gen- 
eral practitioner  simply  because  he  has  abandoned 
the  inspection  of  the  eye.  In  this  group  are  some 
that  call  for  recognition  in  tones  so  loud  that  they 
ought  to  be  detected  at  once  by  any  man  who  will 
use  his  ordinary  powers  of  observation,  while  others 
require  stricter  attention  upon  the  part  of  the  observer. 
Many  of  them,  too,  are  by  no  means  simple  matters. 
When  not  recognized  and  promptly  treated  by  the 
surgeon,  they  go  on,  in  the  ordinary  course  of  events, 
either  to  a  more  or  less  rapid  destruction  of  the  organ 
itself,  or  to  considerable  impairment  of  its  function. 
The  claims  which  the  study  of  this  particular  set  of 
diseases  makes  upon  the  profession  become  all  the 
more  urgent  when  one  reflects  that  in  every  instance 
an  early  diagnosis  may  be  correctly  made  by  the  ex- 
ercise of  the  same  quality  and  amount  of  care  and 
intelligence  which  are  commonly  brought  to  the  in- 
vestigation, let  us  say,  of  affections  of  the  lungs  and 
uterus. 

We  shall  accordingly  proceed  to  consider  this 
group  of  maladies  entirely  from  the  standpoint  of  the 
physician  in  general  practice,  who,  it  is  assumed,  will 
be  confused  rather  than  helped  by  the  introduction  of 
references  to  ophthalmoscopic  findings,  perimetric 
measurements,  and  other  subjects  of  interest  usually 
comprehensible  by  the  specialist  alone. 


EXAMINATION    OF    THE    NORMAL    EYE. 

Just  as  one  studies  the  conditions  under  which 
the  healthy  lungs  and  heart  subserve  their  respective 
functions  before  proceeding  to  an  investigation  of  the 
departures  from  health  to  which  these  organs  are  sub- 
ject, so  it  is  well  to  make  a  study  of  the  normal  eye. 
The  physician  should  cultivate  this  habit  of  observa- 
tion in  the  case  of  the  visual  apparatus  particularly, 
because  so  much  information  as  to  its  condition — 
whether  normal  or  abnormal — can  always  be  learned 

by  SIMPLE   INSPECTION. 

To  be  of  the  greatest  value,  such  an  examination 
should  be  methodical,  and  every  case  should  be  ex- 
amined in  the  same  order.  Of  course,  where  the  pa- 
tient's condition  is  so  obvious  that  it  would  be  a  mere 
waste  of  time  to  follow  out  a  programme  including 
all  the  parts  of  the  eye,  this  rule  may  be  modified;  but 
it  is  safest  to  run  over  the  whole  ground,  so  far  as 
possible,  in  the  great  majority  of  instances. 

The  common,  and  probably  the  best,  plan  that 
can  be  adpoted  is  that  of  proceeding  from  without 
inward,  bearing  in  mind,  meanwhile,  as  many  as  pos- 
sible.of  those  diseased  conditions  which  one  might 
expect  to  find  in  the  particular  locality  under  exami- 
nation. 

Look,  then,  for  a  moment  at  a  pair  of  normal 
eyes.*  When  they  are  directed  straight  forwards  the 

*Only  such  references  will  be  made  to  the  anatomy 
and  physiology  of  the  eye  and  its  accessories  as  are  familiar 


—  4  — 

EYELIDS  are  equally  separated  anti  expose  nearly  the 
whole  of  the  circle  of  the  iris.  Their  edges  are 
smooth,  regular  and  of  uniform  color  throughout  and 
are  fringed  by  a  single  row,  or  by  evenly  distributed 
rows,  of  lashes  (cilia)  all  of  which  point  away  from 
the  underlying  parts  which  they  are  designed  to  pro- 
tect. Each  cilium  can  be  traced  directly  to  its  little 
opening  in  the  edge  of  the  lid,  and  the  space  between 
it  and  its  neighbor  harbors  no  swelling,  dried  secretion 
or  other  abnormal  product. 

The  PALPEBRAL  SKIN  has  the  appearance  of 
healthy  skin  elsewhere  upon  the  face  and  it  is  loose 
enough  to  admit  of  free  movement  of  the  lids,  which 
are  capable  both  of  being  tightly  closed  and  of  being 
opened  to  their  fullest  extent. 

At  the  INNER  CANTHUS  is  the  CARUNCLE,  a  red- 
dish white  prominence  resulting  from  a  reduplication 
of  the  conjunctiva.  Encircling  it,  but  running  in  the 
substance  of  the  lid  margins,  are  the  two  CANALICULI 
— upper  and  lower — whose  external  openings  (the 
puncta)  can  readily  be  seen  when  the  lids  are  slightly 
everted. 

Note  that  the  puncta  are  closely  applied  to  the 


to  the  general  reader.  More  extended  anatomical  and  phy- 
siological descriptions,  as  well  as  fuller  statements  in  the 
pathology  and  microscopy  of  the  subject,  can  be  had  in  most 
text-books.  The  advanced  student  will  also  find  Dr.  Clai- 
borne's  book  on  the  Theory  and  Practice  of  the  Ophthalmo- 
scope very  helpful. 


—  5  — 

eyeball  so  that,  by  a  combined  drainage  and  suction 
action  the  tears  are  carried  along  the  canaliculi  into 
the  LACHRYMAL  SAC  and  then  to  the  nose  by  the 
NASAL  DUCT.  In  the  normal  state  little  or  no  fluid 
of  any  kind  can  be  pressed  out  of  the  sac  through  the 
puncta. 

The  lower  lid  is  everted  by  directing  the  patient 
to  look  upward  while  the  skin  near  the  palpebral 
margin  is,  with  the  forefinger,  pressed  downward 
and  backward  over  the  edge  of  the  orbit.  The/#^te- 
bral  conjunctiva  is  smooth,  of  a  faint  pink  color,  and 
is  thrown  into  folds  just  where  it  extends  forward  to 
cover  the  eyeball.  The  tubules  of  the  Meibomian 
glands  can  also  be  seen  underneath  the  mucous  lining. 
They  discharge  their  fatty  contents  upon  the  free 
margin  of  the  lid  and  assist  in  preventing  an  overflow 
of  tears  upon  the  cheek. 

If  the  subject  under  examination  be  told  to  look 
downward  and  a  probe,  held  in  the  left  hand,  be  laid 
along  the  groove  beneath  the  upper  margin  of  the 
orbit,  the  upper  lid  may  be  everted  and  its  mucous  sur- 
face exposed  and  examined  by  grasping  its  cilia  be- 
tween the  right  thumb  and  forefinger  and  gently 
turning  it  over  the  instrument.  This  little  manoeuvre 
will  be  all  the  more  successful  if  just  before  the 
moment  of  eversion  the  lid  be  pulled,  in  a  direction 
forward  and  downward,  away  from  the  globe  to  which 
it  is  applied. 

The  meibomian  tubules  are  now  more  easily  and 


distinctly  seen  than  are  those  of  the  lower  lid.  The 
conjunctiva,  like  that  of  the  lower  lid,  is  smooth  and 
transparent,  so  that  we  easily  see  the  bloodvessels  or 
other  structures  beneath  it  and  in  its  substance.  The 
outlines  of  the  .TARSAL  CARTILAGE  can  be  made  out, 
while  above  the  superior  border  of  the  latter  are  the 
"folds  of  transmission"  corresponding  to  those  already 
mentioned  as  occurring  in  the  lower  lid.  These 
should  be  carefully  examined  by  telling  the  patient 
to  look  down  at  his  feet  and  at  the  same  time  putting 
the  lid  somewhat  on  the  stretch.  Not  only  are  these 
folds  of  mucous  membrane  especially  subject  to  dis- 
ease, but  they  form  a  favorite  hiding  place  for  foreign 
bodies. 

The  OCULAR  CONJUNCTIVA  in  its  normal  condi- 
tion looks  white  because  it  is  translucent  and  the 
glistening  sclerotic  shines  through  it.  The  blood- 
vessels which  occupy  a  plane  anterior  to  the  latter, 
being  opaque  are  consequently  visible  as  long  as  the 
conjunctiva  remains  normal. 

It  must  always  be  remembered  that  the  blood- 
vessels of  the  conjunctiva  proper  run  both  in  the  sub- 
mucosa  and  in  the  membrane  itself,  and  that  they 
move  when  the  latter  is  moved.  This  fact  is  best 
demonstrated  by  "sliding"  the  ocular  conjunctiva 
over  the  globe.  Pick  out  a  vessel  on  the  healthy  eye- 
ball. Press  upon  it  by  means  of  a  forefinger  placed 
at  the  margin  of  the  lid,  the  latter  being  between 
finger  and  vessel.  If  it  moves  with  the  displaced 


conjunctiva,  it  is  a  conjunctival  vessel.  If  not,  it 
must  lie  deeper  than  the  latter. 

The  underlying  SCLERA  (sclerotic  coat)  presents 
an  even,  uniformly  white  and  smoothly  polished  sur- 
face. Fitted  into  it  at  the  sclero-corneal  junction  is 
the  "watch  glass"  of  the  CORNEA.  No  vessels  ram- 
ify on  its  surface  or  in  its  substance;  it  is  as  transpar- 
ent as  glass  and  forms  an  almost  perfect  circle. 
Place  the  patient  opposite  a  window  and  tell  him  to 
follow  with  his  eyes  the  uplifted  finger  (held  about 
1 8  inches  from  his  face)  which  is  moved  in  various 
directions. 

The  picture  made  by  the  window  frame  upon  the 
cornea  should  be  distinct  and  not  broken  or  distorted, 
showing  that  the  image  is  reflected  from  a  perfectly 
smooth  and  regularly  rounded  surface. 

The  AQUEOUS  HUMOR,  filling  the  anterior 
chamber,  is  equally  well  adapted  to  the  transmission 
of  light,  being  as  clear  as  water. 

The  ANTERIOR  CHAMBER  itself  is  regular  and 
well  defined — not  too  deep,  not  too  shallow. 

The  IRIS  has  a  peculiar  hue  and  brilliancy.  Note 
its  soft,  velvety  appearance,  and  how  closely  it  re- 
sembles its  fellow  of  the  opposite  side.  '  Its  pupillary 
margin  has  the  same  velvety  though  well  defined  ap- 
pearance, and  nowhere  is  it  attached  to  the  cornea  in 
front  or  the  lens  behind. 

A  superficial  observer  might  imagine  that  the 
peripheral  attachment  of  the  iris  is  coincident  with,  or 


nearly  coincident  with,  the  sclero-corneal  junction.  It 
is  well  to  notice,  however,  that  outside  of  this  junc- 
tion there  is  quite  a  large  angular  space  formed  by 
the  iris  and  sclera.  In  the  substance  of  the  latter 
and  close  to  this  angle  lies  the  circular  CANAL  OF 
SCHLEMM. 

Both  PUPILS,  round  arjd  nearly  centrally  placed, 
respond  equally  and  readily  to  the  stimulus  of  light. 
If  a  hand  be  placed  over  each  eye,  so  as  to  entirely 
exclude  the  light,  the  pupils  at  once  dilate,  and  if, 
after  a  minute's  waiting,  first  one  hand  and  then  the 
other  be  removed,  the  irides  contract  quickly,  oscil- 
lating somewhat  until  they  reach  a  state  of  compara- 
tive rest.  They  should,  under  similar  conditions,  be 
of  the  same  size. 

Another  important  experiment  is  the  following: 
The  eyes  are  directed  (in  a  subdued  light)  for  a  min- 
ute to  a  distant  object  and  then  suddenly  fixed  upon 
another  object  a  few  inches  in  front  of  the  nose.  A 
decided  contraction  of  the  pupil  takes  place — a  con- 
traction which  is  followed  by  dilatation,  on  again 
looking  in  the  distance.  This  is  the  action  of  the 

pupil  tO  ACCOMODATION  (R.   14). 

Telling  the  individual  under  examination  to  look 
down  at  his  feet  (so  as  to  present  the  superior  sclero- 
tic surface),  place  the  tips  of  both  forefingers  on  the 
upper  lid  at  the  centre  of  the  upper  orbital  margin. 
Gently  press  the  globe,  first  with  the  tip  of  one  finger 
and  then  with  the  other.  It  yields  a  firm,  yet  elastic 


impression.  This  is  the  NORMAL  TENSION  of  the  eye 
and  by  a  little  practice  the  physician  may  soon  be 
able  to  decide  whether,  in  a  given  instance,  the  ten- 
sion is  more  resisting  or  is  softer  than  normal.  In 
the  first  case  it  would  be  indicated  by  a  plus  sign 
(+i,  +2,  etc.),  according  to  the  degree  of  increase; 
in  the  second  instance  by  a  minus  sign  ( — i, — 2,  etc.) 
to  indicate  the  amount  of  lessened  tension.  Also,  note 
that  moderate  pressure  upon  this  and  other  parts  of  the 
eyeball  is  painless. 

In  youth  the  normal  crystalline  lens  is  invisible, 
but  in  old  people  it  becomes  slightly  hazy,  and  may 
usually  be  seen  by  concentrating  the  light  from  a 
lamp  or  gas  jet  (placed  at  the  side  of  the  patient's 
face)  upon  it  by  a  convex  lens  having  a  focus  of-  from 
5-8  centimetres  (2-3  inches).  Such  a  glass  is  readily 
obtainable  from  any  optician  or  instrument  maker, 
and  is  indispensable  in  making  a  proper  examination 
of  the  eye.  By  its  aid  this  method  of  OBLIQUE  IL- 
LUMINATION, as  it  is  called,  can  be  applied  to  search- 
ing for  foreign  bodies  and  opacities  in  the  cornea, 
changes  in  the  iris,  opacities  in  the  lens  and  lens  cap- 
sules, and  to  many  other  uses — as  we  shall  hereafter 
see. 

The  glass  is  held  between  the  thumb  and  index 
finger,  the  hand  being  steadied  by  touching  with  one 
or  more  fingers  the  forehead  or  cheek  of  the  patient, 
and  the  rays  of  light  are  directed  sideways  (die  seitliche 
Beleuchtung  of  the  Germans)  and  brought  to  a  focus 


on  the  part  of  the  eye  to  be  examined.  This  point  of 
light  may  be  made  to  play  all  over  the  external  eye 
and  even  to  illuminate  growth,  foreign  bodies,  clots, 
etc.,  situated  as  far  back  as  the  vitreous  body,  behind 
the  lens. 

Under  normal  conditions  neither  globe  should 
protrude  between  the  lids,  nor  should  one  eye  be 
more  prominent  than  the  other,  although  it  must  not 
be  forgotten  that  many  persons  exhibit  a  shallow 
facial  development  which  gives  to  their  perfectly 
normal  eyes  the  appearance  of  having  been  pushed 
forward  from  behind. 

In  this  connection  it  is  well  to  become  acquaint- 
ed with  the  impression  given  to  one's  fingers — little 
fingers  to  be  preferred — in  EXPLORING  THE  ORBIT. 
Note  the  position  of  the  pulley  of  the  superior  oblique 
muscle,  the  canthal  ligament,  and  the  notches  or  for- 
amina for  the  infra-  and  supra-orbital  nerves,  so  that 
they  may  not  be  mistaken  for  abnormalities. 

Some  attention  should  be  given  to  the  BLOOD 
SUPPLY  of  the  superficial  portions  of  the  visual  appa- 
ratus. The  movable  vessels  of  the  conjunctiva  have 
already  been  noticed.  It  is  well  to  note  their  num- 
ber, their  size,  and  the  fact  that  they  do  not  affect 
the  coloration  of  the  mucous  membrane  to  which 
they  are  supplied.  Then  there  are  in  addition  to 
these  a  few  rather  large  and  tortuous  vessels  (anterior 
ciliary  arteries]  which  lie  in  the  ocular  sub-con  juncti- 
val  tissue  and  run  forward  on  the  globe  until,  at  a 


point  one  or  two  millimetres  from  the  cornea,  they 
pierce  the  sclerotic,  and  supply  it,  the  iris,  and  the 
ciliary  body.  These  arteries  give  off  small  and  nearly 
straight  (episcleral )  branches,  which  form  a  close  net- 
work of  vessels  around  the  corneal  margin.  They  are 
invisible  in  health.  When  visible  (and  not  moving 
when  the  ocular  conjunctiva  is  slid  over  the  sclera), 
they  point  to  irritation  or  inflammation  of  the  iris, 
cornea,  or  some  deeper  structure. 

The    EQUILIBRIUM    OF    THE    OCULAR  MUSCLES  (R. 

47),  may,  in  normal  eyes,  be  tested  as  follows:  Hav- 
ing covered  with  the  left  hand  one  of  the  person's 
eyes,  tell  him  to  "fix,"  /.  <?.,  look  steadily  at,  the  tip  of 
a  pencil  or  other  small  object  held  in  the  right  hand 
about  ten  inches  in  front  of  his  nose.  Then  quickly 
transfer  the  left  hand  to,  and  cover  up,  the  other  eye, 
watching  closely  the  recently  uncovered  eye.  When 
the  various  muscles  of  the  eye  are  properly  balanced, 
the  uncovered  eye  will  not  turn  out  or  in,  indeed  it 
will  not  be  moved  at  all,  to  fix  the  object  held  in 
front  of  the  face.  On  the  other  hand,  there  is  mus- 
cular weakness  present  (which  not  infrequently  gives 
rise  to  troublesome  symptoms)  should  the  second  eye 
move  inwards  or  outwards  in  its  efforts  to  see  dis- 
tinctly the  object  in  front  of  it. 

Also,  both  eyes  should,  first  singly  and  then  to- 
gether, follow  the  movement  of  an  object  moved  to 
and  fro,  upward  and  downward,  in  front  of  the  eye, 
until  portions  of  the  cornea  are  covered.  That  is  the 
excursion  of  the  normal  eyeball. 


Having  in  this  way  made  an  objective  examination 
of  the  normal  eye,  it  is  advisable  to  investigate  some 

SUBJECTIVE  PHENOMENA. 

First,  the  VISUAL  ACUITY  (R.  2).  This  is  nothing 
more  than  the  ability  which  the  eye  possesses  of  rec- 
ognizing the  form  of  objects.  To  make  a  distinct 
impression  upon  the  retina,  objects  must  be  of  a  cer- 
tain size  which  is  found  to  bear  a  definite  relation  to 
their  distance  from  the  eye — the  nearer  they  are 
the  smaller  they  may  be;  the  farther  away  the 
larger  they  must  be.  The  plan  commonly  adopted 
is  to  choose  letters  of  the  smallest  size  which  can 
be  readily  distinguished  by  the  normal  eye  at  6 
metres  (20  feet).  These  letters  in  the  ordinary 
series  (Snellen's  test  types)  are  marked  |-  or  fg-, 
indicating  that  the  eye  which  reads  them  at  this  dis- 
tance— 6  metres,  or  20  feet — has  the  full  acuteness  of 
vision.  If  from  the  same  distance  the  letters  (twice 
as  large  as  those  marked  f)  marked  T6j  or  f  #  are  the 
smallest  that  can  be  read,  the  person's  vision  is  only 
one-half  the  normal.  And  so  on  through  the  whole 
series  down  to  -fo  or  ^Vo>  the  numerator  of  the  frac- 
tion always  designating  the  distance  from  the  test 
types  at  which  the  patient  stands,  the  denominator 
the  distance  at  which  the  test  line  should  be  distin- 
guished by  the  normal  eye.  It  may,  however,  happen 
that  the  patient  cannot  read  even  the  largest  letter  of 
the  test  types.  In  that  case  he  should  gradually  ap- 
proach until  he  is  able  to  distinguish  it,  and  the  num- 


—  13  — 

her  of  metres  (or  feet)  distant  from  the  types,  divided 
by  60  (or  200),  will  give  the  amount  of  his  visual 
power.  For  example:  A  patient  distinguishes  with 
his  right  eye  the  largest  letter  of  Snellen's  types  at  2 
metres  (6l/z  feet).  His  left  eye,  however,  can  read  at 
6  metres  the  line  marked  ^  or  -ffo.  Shortly  ex- 
pressed, we  would  say:  Right  Eye  (or  R.)  Vision  (or 
V.)  =  /o-  (or  yjhr);  L.  V.  =  ^  (or  TW)-  But  the 
ability  to  distinguish  form  may  be  further  reduced, 
and  then  we  find  out  at  what  distance  from  his  face 
the  patient  can  count  one's  fingers.  Here  V.  = 
fingers  at  10  inches,  or  whatever  the  distance  may  be. 
Finally,  the  patient  may  be  so  blind  as  to  able  to  dis- 
tinguish between  light  and  darkness  only,  when  V.  = 
p.  1.,  or  perception  of  light.  In  all  these  cases  one 
eye  at  a  time  is  examined,  the  other  being  covered 
with  the  hand  or  a  light  bandage  which  does  not 
press  upon  the  eye.  Snellen's  test  types  are  readily 
obtainable  from  any  medical  bookseller,  and  are  very 
useful  in  the  diagnosis  of  diseases  of  the  eye. 

In  addition  to  the  use  of  these  test  types — which 
are  employed  for  examining  distant  vision  only — 
there  are  tests  for  near  vision  (R.  15.17).  Those  com- 
monly employed  are  Snellen's  and  Jaeger's.  The 
latter  correspond  to  ordinary  type,  and  are  numbered 
from  i,  the  smallest,  to  20,  the  largest.  Persons  who 
have  full  distant  visual  acuity  are  usually  able  to  read 
the  finest  print,  and,  vice  versa,  those  who  are  able  to 
read  Jaeger  No.  i  have  good  distant  vision.  The 


—  14  — 

exceptions  to  both  these  statements  are  numerous  and 
•cannot  be  considered  here. 

PERCEPTION  OF  COLOR  is  one  of  the  functions  of 
the  healthy  eye,  a  function  which  (congenitally  de- 
ficient in  3  per  cent,  of  all  persons)  becomes  impaired 
or  abolished  in  certain  diseases.  The  normal  eye 
should  immediately  recognize  the  various  colors  and 
shades  of  color.  Samples  of  Berlin  wools  make  the 
best  test  objects. 

The    EXAMINATION    OF     THE     EYES    OF     CHILDREN 

requires  the  exercise  of  considerable  tact  combined 
with  the  greatest  care  and  gentleness. 

Except  in  special  cases,  to  be  spoken  of  later, 
most  information  can  be  obtained  by  drawing  the 
little  one's  attention  to  some  toy  which  is  moved  in 
various  directions  in  front  of  its  face.  This  will,  in 
most  instances,  enable  the  observer  to  see  the  cornea, 
the  iris,  and  the  lens,  and  permit  a  fairly  satisfactory 
examination  of  the  external  eye  to  be  made.  When 
there  is  much  photophobia,  or  the  lids  are  swollen,  or 
where  from  any  cause  the  child  is  unable  or  unwilling 
to  open  its  eyes,  it  may  be  necessary,  before  a  proper 
examination  can  be  obtained,  to  drop  into  the  eyes  a 
few  drops  of  a  weak  (2  per  cent.)  solution  of  cocaine, 
and  then  to  open  them  by  means  of  lid  retractors,  a 
pair  of  which  should  form  a  part  of  every  practitioner's 
armamentarium.  It  is  in  every  way  most  satisfactory 
to  place  the  little  one's  head  between  the  operator's 
knees,  over  which  a  towel  has  been  thrown.  The 


nurse  holds  the  child  lying  on  her  lap,  and  grasps  the 
hands  in  one  of  hers,  while  the  surgeon  has  both  his 
hands  free  to  use  the  retractors,  apply  remedies,  etc. 
It  is  sometimes  necessary  to  administer  chloroform. 

It  is  possible,  although  it  requires  some  practice, 
to  evert  both  lids  in  infants  by  pressure  at  the  orbital 
margins.  The  palpebral  skin  is  directed  over  the  or- 
bital margin  backwards  and  inwards  by  the  thumb  or 
finger-nail,  and  the  conjunctiva  is  effectually  exposed. 
The  crying  which  the  child  indulges  in  helps  rather 
than  hinders  this  manoeuvre. 


LESSON  II. 

THE  EYE  IN  DISEASE. 

Examination  of  the  Patient — The  History  of  the  Case — Signs 
and  Symptoms — The  Visual  Acuity — Everting  the  Lids 
— The  Bifocal  Illumination — The  Examination  by  Re- 
flected Light — Some  Points  in  Diagnosis — Abnormal 
Tension  and  Lacrymation — The  Ocular  .Blood  Supply 
in  Disease — Remedies  Commonly  Used  in  Ophthalmic  Prac- 
tice— Leeches,  Natural  and  Artificial — Heat  and  Cold — 
Blisters — Atropine,  Homatropine,  and  Duboisine — Es- 
erine  and  Pilocarpine — Boracic  Acid  and  Nitrate  of 
Silver — Other  Remedies — Bandages  and  Shades — Gog- 
gles and  Colored  Glasses — Eye  Cups  and  Eye  Droppers 
— Irrigation  of  the  Eye — The  Cautery — Preparing  for 
Operations — Antiseptic  Precautions — A  Clean  Surgeon, 
Clean  Instruments,  and  a  Clean  Patient. 

One  should  preserve  the  same  order  in  examin- 
ing a  patient  suffering  from  an  ocular  affection  that 
is  commonly  followed  in  diseases  of  other  parts  of  the 
organism.  Having  first  noted  the  patient's  age  (66, 
60,99)  obtain  as  complete  a  history  of  the  case  as  pos- 
sible. Has  he,  for  instance,  any  other  affection,  local 
or  general,  which  is  likely  to  affect  the  diseased  eye  or 
which  may  be  the  chief  cause  of  the -trouble  (117)? 
When  did  the  ocular  affection  first  appear  ?  Did  it 
come  on  slowly  or  suddenly  (112)?  Has  it  affected 
one  eye  or  both  (120)?  If  both  are  diseased  when  did 
the  second -one  become  involved  (68)?  To  what 
cause  does  the  patient  or  his  friends  attribute  the  dis- 


ease  ?  What  signs  and  symptoms  have  been  most 
prominent  during  the  illness  ?  Has  there  been  any 
pain  (57,  81)?  If  so  inquire  into  its  position,  its  char- 
acter and  its  frequency.  Does  it  grow  worse  at  any 
particular  period  of  the  twenty-four  hours  (84)  ?  Is  there 
any  "discharge"  from  the  eyes?  If  so,  does  it  cause 
adhesion  of  the  lids  ?  Has  the  patient  observed 
specks  or  spots  (20)  floating  in  front  of  his  eyes,  any 
halos  about  lamps  or  gas  jets  (114),  or  does  he 
occasionally  notice  sparks,  or  balls  of  fire,  or  colored 
light.  Is  the  disease  decreasing,  increasing,  or  is  it  at 
a  standstill  ?  What  treatment,  if  any,  has  so  far  been 
given  ? 

These  questions  should,  I  think,  be  asked  in  the 
great  majority  of  instances  and  the  substance  of  the 
answers  recorded  in  the  case  book  which  every  care- 
ful physician  will  keep.  Next,  the  examiner  will  rely 
upon  his  own  observations  and  note  carefully  any- 
thing abnormal  about  the  patient  which  he  may  think 
has  any  bearing  on  the  ocular  disease.  These  may 
be  signs  of  syphilis,  congenital  or  acquired  (66),  of 
tuberculosis  of  emaciation  or  its  opposite,  of  pulsa- 
tion in  the  cervical  veins  an  abnormal  pulse,  flushed 
face  and  so  on. 

The  successful  ophthalmologist  is  ever  alive  to 
these  important  general  signs  of  disease. 

The  visual  acuity  may  at  this  stage  be  noted  (12) 
as  it  is  commonly  desirable  to  see  what  interference 
with  vision  has  been  produced  by  the  disease,  and 


—    .8  — 

later  on  what  improvement  (if  any)  has  resulted  from 
the  treatment.  In  applying  this  test  where  the  eye  is 
inflamed  it  is  always  well  for  obvious  reasons  to  have 
the  patient's  immediate  surroundings  in  partial  dark- 
ness and  to  make  a  note  of  the  fact  so  that  subse- 
quent examinations  may  be  made  under  similar  cir- 
cumstances. 

Now  it  is  probably  time  to  specialize  and  to  pro- 
ceed to  an  examination  of  the  ocular  region. 

The  more  acute  the  disease  (and  especially  if  it 
be  an  affection  of  the  palpebrse,  cornea,  or  iris),  the 
more  decidedly  are  the  tissues  of  the  temple,  brow, 
face  and  lids  likely  to  be  swollen  and  hot.  The 
superficial  vessels  of  these  parts  will  then  be  distinctly 
seen  running  through  the  puffy  skin. 

The  hot  tears,  mingled  it  may  be  with  abnormal 
secretion,  bathe  the  lower  lids  and  escape  at  the  outer 
and  inner  canthi  and  thus  add  another  irritant  to  the 
inflamed  parts. 

The  nasal  duct  is  filled  to  overflowing  with  the 
lachrymal  fluids  and  the  patient  finds  it  necessary  to 
use  his  handkerchief  freely. 

Not  infrequently  a  pad  of  cotton  wool,  enclosed 
in  a  not  over  clean  bandage,  is  worn  over  the  eye. 
This  absorbs  the  altered  secretion  and  is  thus  made 
to  act  as  a  kind  of  morbific  poultice  which  further  in- 
creases the  discomfort  of  the  patient  by  producing  ex- 
coriations of  the  palpebral  skin. 

Our  first  duty  is  to  cleanse  such  an  eye  with  a 


warm  and  mild  antiseptic  solution — say  of  boracic 
acid — gently  applied  with  some  aseptic  cotton  wool. 
If  marked  photophobia  be  present  instilling  a  few 
drops  of  a  two  per  cent. — 10  grains  to  the  ounce  — 
solution  of  cocaine  will,  in  ten  or  fifteen  minutes,  al- 
low of  a  more  comfortable  and  more  thorough  ex- 
amination of  the  affected  parts. 

It  is  good  policy  to  evert  the  lids  in  all  such 
cases  (5)  when  it  is  not  specially  contra-indicated, 
and  study  the  condition  of  their  ocular  surface  (M. 
5,  and  17).  The  trouble  may  be  entirely  there. 

The  cornea,  iris  and  sclera  should  now  be  care- 
fully looked  over,  first  with  ordinary  illumination  and 
then,  if  the  condition  of  the  patient  will  allow  it,  by 
means  of  the  focal  illumination  (9).  A  good  plan, 
when  one  wishes  to  explore  carefully  the  details  of  a 
lesion  of  the  cornea,  sclera,  or  even  the  conjunctiva, 
is  to  proceed  as  above  and  then  to  use  in  addition,  as 
a  magnifying  glass,  a  second  lens  held  in  the  other 
hand.  By  this  means  a  most  accurate,  though  en- 
larged, picture  of  the  part  can  be  had.  In  the  same 
way  opacities  of  all  kinds  in  the  cornea,  alterations  in 
the  iris,  and  most  changes  in  the  lens  structure  can  be 
made  out. 

But  we  should  have  other  methods  of  diagnosis. 
For  determining  the  presence  or  absence  of  opacities 
in  the  aqueous,  lens,  and  vitreous  body,  when  an  ex- 
amination is  not  prevented  by  a  too  opaque  cornea,  it 
is  a  very  good  plan  to  examine  these  media  in  a  dark 
room  with  the  light  from  a  single  gas  jet  or  lamp. 


2O    

Both  being  seated,  the  examiner  faces  the  patient, 
at  the  side  of  whose  head  is  placed  the  light,  and  the 
surgeon  throws  its  rays  upon  the  pupil  under  exami- 
nation by  means  of  a  small  concave  mirror,  pierced 
with  a  central  opening,  held  in  front  of  his  eye.  The 
hole  in  the  mirror  should  not  be  more  than  3  jn.  m. 
in  diameter.  It  is  always  justifiable  in  making  this- 
particular  examination  to  dilate  the  pupil.  A  couple 
of  drops  of  a  two-per-cent.  cocaine  solution  will  do 
this;  it  is  a  harmless  mydriatic  whose  effects  pass  off 
in  a  few  hours.  If  the  observer's  eye  be  placed  about 
30  cm.  in  front  of  the  patient,  he  will  see  that  an  un- 
interrupted reddish  reflex  (from  the  retina)  has  taken 
the  place  of  the  previously  black  pupil.  Opacities  of 
any  kind  in  any  of  the  media  will  then  appear  as 
small  black  objects  in  this  red  field.  If  the  patient 
be  now  directed  to  look  slowly  up  to  the  ceiling  and 
then  at  the  mirror,  the  surgeon  will  be  able  to  judge, 
with  a  little  practice,  whether  the  objects  change  their 
places  relative  to  their  surroundings.  If  they  do, 
they  are  probably  in  the  vitreous.  If  not,  they  are 
probably  in  the  lens.  These  two  methods  should  be 
employed  in  the  order  named  and  will  seldom  fail  to 
detect  the  presence  of  abnormal  products  in  the 
optic  media — a  very  common  cause  of  disturbed 
vision. 

Reference  has  already  been  made  to  the  normal 
blood  supply  (10).  The  blood  vessels  of  the  eye  are 
almost  always  affected  in  disease  of  the  organ,  and 


21    

the  surgeon  should  be  careful  to  note  in  each  case,  as 
a  means  of  diagnosis,  to  what  extent  the  circulation 
has  been  disturbed. 

Next  the  tension  of  the  globe  should  be  tested' 
(9)  and  the  examiner  may  inquire  at  the  same  time 
whether  the  pressure  causes  any  pain — whether  the 
parts  are  tender  (9). 

When  lachrymation  is  a  constant  symptom  (with- 
out definite  signs  of  acute  disease)  pressure  should  be 
made  over  the  lachrymal  sac  to  discover  whether  by 
this  manceuver  any  abnormal  secretion — pus  or  muco- 
pus — can  be  squeezed  out  (50). 

REMEDIES  COMMONLY  USED  IN  OPHTHALMIC  PRACTICE. 

It  is  generally  agreed  that  local  blood-letting  is 
a  valuable  agent  for  the  reduction  of  most  deep  seated 
and  acute  inflammations  of  the  eye  (89).  The  arti- 
ficial leech  answers  very  well  for  this  purpose.  I 
much  prefer  it  to  the  living  animal,  which  is  often  un- 
certain in  its  action.  Of  course,  the  amount  of  blood 
to  be  withdrawn  and  the  frequency  of  the  application 
will  depend  upon  the  severity  of  the  disease  and  the 
effect  of  the  remedy.  Very  little  effect  is  produced 
unless  half  an  ounce  of  blood  is  withdrawn.  The 
favorite  spot  for  the  operation  is  the  temple  half  an 
inch  from  the  outer  margin  of  the  orbit. 

HEAT  is  often  applied  after  or  in  conjunction 
with  the  leeching  This  may  be  in  the  form  of  steam, 
hot  water,  or  hot  compresses.  A  good  plan  for  ap- 


22    

plying  the  first  named  is  to  take  a  tumbler,  heat  it 
and  fill  it  half  full  of- boiling  water.  The  mouth  of 
the  tumbler  is  then  closely  applied  to  the  eye  and 
brow,  which  may  be  thus  well  steamed  for  five  or  ten 
minutes  at  a  time  as  often  as  necessary.  If  hot  com- 
presses are  used,  the  applications  should  be  made  for 
the  same  length  of  time  and  at  intervals. 

The  practice  of  poulticing  or  of  using  hot  appli- 
cations to  the  eye  for  hours  at  a  time  appears  to  me 
to  be  harmful  instead  of  helpful. 

When  COLD  is  employed  (64)  pieces  of  flannel 
four  inches  square  may  be  kept  on  a  block  of  ice,  the 
the  lower  one  being  changed  when  needed  for  the 
one  just  removed  from  the  eye  In  the  absence  of 
an  attendant,  the  patient  may  often  do  this  himself. 

BLISTERS  are  valuable  adjuncts  to  eye  surgery r 
when  judiciously  employed.  They  may  be  applied 
above  the  brow,  at  its  outer  edge,  or  to  the  temple. 

ATROPINE  is  one  of  the  most  valuable  drugs  we 
possess.  One  drop  of  a  one  per  cent,  solution  pro- 
duces wide  dilatation  of  the  pupil  in  half  an  hour. 

This  action  begins  fifteen  minutes  after  it  is  intro- 
duced. Three  hours  afterwards  the  accommodation 
(R.  14)  is  fully  paralyzed,  and  the  effects  do  not  pass 
off  in  some  patients  for  a  week;  in  others,  a  shorter 
time  is  required.  It  is  well  to  say  here  that  solutions 
of  atropine  and  the  other  alkaloids  used  in  ophthal- 
mic surgery,  if  they  do  not  actually  deteriorate  in 
time,  become  cloudy  from  the  formation  of  moulds.. 


—  23  — 

'  It  is  consequently  advisable  to  have  them  made  up 
with  a  solution  (1:5000)  of  mercuric  chloride.  In  my 
hands  a  saturated  solution  of  boracic  acid,  used  by 
many,  has  not  prevented  the  growth  of  these  forms  of 
life. 

HOMATROPIXE  resembles  atropine  in  its  effects 
upon  the  pupil  and  accommodation,  except  that  it 
may  be  said  to  begin  its  action  earlier  and  to  run  its 
course  sooner  than  the  former.  In  twenty- four  hours 
after  the  instillation  of  a  few  drops  of  the  one  per 
cent,  solution,  the  effects  upon  the  accommodation 
have  mostly  passed  away.  In  consequence  of  these 
qualities,  it  is  employed  for  dilating  the  pupil  when 
the  ophthalmoscope  is  to  be  used. 

DuBoisiA  is  a  quick  and  powerful  though  not  so 
lasting  a  mydriatic  as  atropine,  and  is  employed  (in 
about  the  same  dose)  instead  of  the  latter  when  it 
produces  irritation  or  inflammation  of  the  conjunctiva 
and  swelling  of  the  lids. 

Of  the  drugs  which  contract  the  pupil,  myotics, 
which,  generally  speaking,  have  an  opposite  effect  to 
agents  of  the  atropine  class,  the  most  important  is 
ESERIXE. 

This  alkaloid  is  derived  from  the  Calabar  bean, 
and  is  also  known  by  the  name  physostigmine.  It  is 
usually  given  in  weaker  doses  than  atropine  (say  )4  to 
2  grains  to  the  ounce)  on  account  of  the  frontal  pain 
and  twitching  of  the  eyelids  which  it  causes.  For 
this  reason,  also,  it  is  sometimes  combined  with 


—   24  — 

cocaine  (4  grains  to  the  ounce).  The  pain,  though 
severe,  soon  passes  off,  and  when  it  is  found  neces- 
sary to  instil  the  drug  for  some  length  of  time,  less 
and  less  irritation  is  produced  until,  finally,  its  use  is 
not  followed  by  the  first  effects.  Full  contraction  of 
the  pupil  with  spasm  of  accommodation  is  brought 
about  in  fifty  minutes.  Recovery  takes  place  in  three 
days. 

PILOCARPINE,  an  alkaloid  obtained  from  jabo- 
randi,  is  a  myotic,  but  weaker  in  its  action  than  eser- 
me.  It  is>in  addition,  a  powerful  sudorific  and  expec- 
torant, and  in  doses  of  }&-%  grain  is  much  used  hypo- 
dermically  in  diseases  of  the  eye — especially  in  choro- 
iditis,  and  in  inflammations  and  detachment  of  the 
retina.  "' 

If  used  locally,  like  eserine,  a  one  per  cent,  solu- 
tion is  the  usual  strength. 

COCAINE  (from  the  erythro^ylon  coca]  is  a  late  but 
extremely  valuable  contribution  to  ocular  therapeu- 
tics. With  its  aid  many  operations  hitherto  per- 
formed with  the  aid  of  ether  or  chloroform  may  now 
be  undertaken  while  the  eye  is  under  its  anaesthetic 
influence  alone.  When  first  dropped  into  the  eye  a 
two  per  cent,  solution  causes  a  little  smarting.  This 
passes  off  in  a  minute  or  two  and  the  conjunctiva  and 
cornea  become  completely  anaesthetized  in  from  four 
to  six  minutes. 

Five  minutes  afterwards  the  numbness  begins  to 
pass  off  and  the  normal  state  is  reached  in  another 


—  25  — 

quarter  of  an  hour.  The  alkaloid  causes  contraction 
of  the  blood  vessels,  whitens  the  sclera,  dilates  the 
pupils  and  slightly  weakens  the  accomodation  power. 
The  mydriasis  may  remain  for  twenty-four  hours. 
Cocaine  greatly  increases  the  mydriatic  effect  of  atro- 
pine.  In  the  same  way  mixtures  of  homatropine  and 
cocaine  are  used  for  paralyzing  the  accomodation  in 
making  examinations  for  the  correction  of  refractive 
errors.  A  temporary  but  very  effectual  result  may 
thus  be  obtained  by  using  one  drop  of  a  one  per  cent. 
solution  in  castor  oil  of  these  last  named  alkaloids.*^ 

For  operative  purposes  solutions  of  cocaine 
should  be  made  fresh  with  distilled  or  boiled  water. 
Not  more  than  three  or  four  instillations  (within  five 
minutes)  are  needed  for  cataract  extraction,  and  a  two 
per  cent,  solution  is  quite  strong  enough.  Small 
tumors  (chalazia,  etc.)  may  under  its  influence  be  re- 
moved without  pain  if  a  4  per  cent,  solution  be  in- 
jected under  the  skin  or  about  the  growth.  Cocaine 
is  also  valuable  when  it  is  found  necessary  to  apply 
caustic  irritants  to  the  external  eye.  Here  it  is  well 
to  paint  over  the  spot  to  be  burned  with  a  10  per  cent. 
solution  of  the  alkaloid.  If  freely  used  it  causes  dry- 
ness  and  loosening  of  the  corneal  epithelium.  This 
may  usually  be  prevented  by  ordering  the  patient  to 
keep  the  affected  eye  closed. 


*  See  author's  paper  in  the  Journal  of  Ophthalmology, 
'Otology  and  Laryngology,  July,  1889 

1  fir 


—    26    — 

Lamella  or  discs.  A  very  elegant  method  of  pre- 
serving and  applying  these  alkaloids  is  in  the  form  of 
minute  discs  of  gelatine.  Several  reliable  chemists 
make  them,  and  they  combine  the  advantages  of  a 
portable  form,  definite  dose  and  complete  preserva- 
tion. One  of  these  small  discs  will  adhere  to  a 
damp  match,  camel  hair  pencil  or  probe,  and  may  be 
laid  in  the  conjunctival  sac,  or  against  the  sclera,  the 
lower  lid  being  meantime  drawn  down  and  the  patient 
told  to  look  up. 

Numerous  metallic  salts  are  employed  by  oph- 
thalmic surgeons.  These  are  usually  directed  against 
affections  of  the  conjunctiva,  cornea  and  sclera.  Prob- 
ably the  most  commonly  used  of  these  is  BORACIC 
ACID.  A  saturated  solution  contains  about  20  grains 
to  the  ounce  of  water.  This  and  weaker  solutions 
give  little  or  no  pain  when  applied  to  the  eye  and 
they  make  mild  and  effective  antiseptic  lotions.  The 
salt  itself  when  applied  to  the  eye  is  practically  non- 
irritant.  An  ointment  is  also  in  common  use. 

BORAX  (the  biborate  of  sodium)  has  a  weaker 
antiseptic  action  than  the  former,  but,  in  about  the 
same  dose,  is  used  as  a  cleansing  lotion  to  the  eye. 

OXIDES  OF  MERCURY  play  an  important  role  in 
ocular  therapeutics.  A  common  ointment  is  Pagens- 
techer's  : 

Yellow  oxide  of  mercury 24  grains. 

Vaseline  or  cold  cream i  oz. 

This  makes  a  strong  mixture  and  it  is  always  well 


to  prescribe  a  much  weaker  one  for  the  patient's  use. 
The  red  oxide  is  used  in  the  same  proportion  and  for 
much  the  same  purposes. 

The  ointment  of  the  acid  nitrate  of  mercury, 
CITRINE  OINTMENT,  is  preferred  by  some  surgeons  to 
the  foregoing.  Instead  of  the  neat's-foot  oil,  it  may 
be  made  with  cod-liver  oil.  * 

SOLUTIONS  OF  PERCHLORIDE  OF  MERCURY,  in 
various  strengths,  are  useful  as  antiseptic  lotions,  and 
are  widely  employed  for  cleansing  the  conjunctiva 
and  eyelids  previous  to  and  after  operations.  For 
this  purpose  a  strength  of  1:5000  is  about  right. 

CALOMEL  in  fine  powder,  blown  into  the  eye  with 
a  blower,  or  flicked  with  a  camel's-hair  brush,  is  use- 
ful in  chronic  corneal  diseases. 

When  IODOL  or  IODOFORM  are  employed  in  eye 
surgery,  they  are  used  as  a  strong  ointment  with  vas- 
eline or  in  the  form  of  impalpable  powder. 

ZINC  CHLORIDE  or  SULPHATE  (%  to  2  grains  to 
the  fluidounce  of  water)  is  a  valuable  astringent. 

ALUM,  in  stick  or  crystal,  is  a  useful  application 
in  chronic  forms  of  conjunctivitis.  A  lotion  (4  to  10 
grains  to  the  ounce)  is  also  used  in  mild  forms  of 
acute  and  chronic  catarrh  of  the  conjunctiva.  *^ 

SULPHATE  OF  COPPER,  in  the  form  of  pencils  or 
of  a  smoothly  pointed  crystal,  is  a  classical  remedy  in 
trachoma.  It  is  a  mild  escharotic,  and  its  use  causes 
considerable  smarting.  A  few  drops  of  cocaine  so- 
lution, 2  per  cent.,  will  relieve  that.  A  good  prepar- 


—    28    — 

ation  to  be  used  instead  of  bluestone  is  the  old  lapis 
divinus,  made  as  follows: 

Potassium  nitrate,      \ 

Alum,  I  of  each  i  part. 

Copper  sulphate,        J 

Fuse  together,  and  add  camphor  -fa  of  the  whole. 
To  be  run  into  moulds  and  kept  in  a  stopped  bottle. 

LEAD  ACETATE  is  of  use  inconjunctival  and  lach- 
rymal diseases.  It  should  not  be  employed  when  the 
cornea  is  involved,  else  staining  of  the  latter  may  re- 
sult. A  common  formula  is: 

Liq.  plumbi  subacetatis f.  3  j- 

Aqua  destill Oj. 

Twenty  per  cent,  of  alcohol  added  makes  a  cooling  ex- 
ternal application  to  inflamed  lids. 

NITRATE  OF  SILVER  is  one  of  the  best  astringent 
caustics  we  possess,  and  it  is  found  to  act  admirably 
in  many  external  affections  of  the  eye.  It  should 
never  be  used  by  the  patient  stronger  than  a  half  per 
cent,  solution  in  distilled  water.  More  powerful  mix- 
tures had  better  be  applied  by  the  oculist  himself. 
Although  the  action  of  this  silver  salt  is  limited  by 
the  formation  with  the  tissues  of  an  inert  albuminate 
of  silver,  it  is  always  advisable  to  have  at  hand  a  solu- 
tion of  salt  and  some  water.  When  strong  solutions 
are  used,  the  excess  of  the  nitrate  may  be  neutralized 
and  prevented  from  affecting  the  surrounding  parts 
by  brushing  the  latter  with  the  saline  solution,  which, 


—    29    — 

with  the  resulting  chloride  and  some  shreds  of  albu- 
minate  of  silver,  can  be  removed  by  subsequent  appli- 
cations of  pure  water.  This  is  the  best  method  of  ap- 
plying solutions  of  silver  nitrate  to  young  children — 
as,  for  instance,  in  ophthalmia  neonatorum  (M.  34). 
If  this  remedy  be  persisted  in  for  weeks  or  months  it 
may  stain  the  conjunctiva.  The  solid  salt  ought  not 
to  be  applied  to  the  conjunctiva,  although  such  inti- 
mate mixtures  as  the  "  mitigated  stick  "  may  be  used 
without  danger.  The  formula  for  the  latter  is: 

Nitrate  of  silver i  part. 

Nitrate  of  potash 2  parts. 

Fuse  and  run  into  moulds. 

All  preparations  of  silver  nitrate  should  be  kept 
out  of  the  light. 

TANNIC  ACID,  and  mixtures  of  it  with  alum, 
glycerine,  and  water,  are  popular  with  some  ophthal- 
mic surgeons.  My  own  experience  of  it  has  not  im- 
pressed me  favorably.  The  so-called  glycerite  of  tan- 
nin has  been  recommended  for  trachoma  (M.  45). 

BANDAGES  for  the  eye  are  of  two  kinds.  The 
first  is  used  when  it  is  desired  to  exclude  all  light, 
and  for  this  purpose  nothing  is  better  than  well- 
washed  white  flannel.  When  the  purpose  is  to  retain 
dressings  in  place,  cheese-cloth  or  muslin  is  much  to 
be  preferred.  When  once  removed  from  the  eye, 
a  fresh  bandage  ought  to  be  used,  the  flannel  being 
saved,  the  cheese-cloth  thrown  away. 


—  3°  - 

BORATED    OR    SALICYLATED    COTTON    WOOL,    kept 

clean  in  a  tin  box,  makes  the  best  dressing  for  most 
ophthalmic  cases. 

GOGGLES  for  excluding  the  light  and  for  protect- 
ing the  eyes  from  dust  and  wind  are  made  of  a  colored 
glass  front,  whose  sides  are  fine  meshed  wire.  They 
are,  when  complete  protection  is  desired,  to  be  pre- 
ferred to  coquilles  (dome-shaped  glasses),  or  plain 
colored  spectacles,  although  the  latter  have  the  ad- 
vantage so  far  as  appearance  goes.  Opticians  keep 
these  protective  glasses  in  various  tints  of  "smoke" 
and  blue. 

SHADES  are  made  of  cardboard  for  one  or  both 
eyes.  The  home-made  article  is  objectionable,  in 
that  it  is  usually  fashioned  so  that  it  touches  the  lids 
or  eyelashes.  It  then  shortly  becomes,  surgically, 
unclean  from  the  ocular  secretions,  and  for  this  rea- 
son is  a  source  of  danger. 

EYE  CUPS  are  made  to  fit  the  edges  of  the  orbit, 
brow,  and- nose,  with  the  idea  of  effectually  bathing 
the  eye.  Filled  with  the  medicated  solution,  the  cup 
is  accurately  applied  to  the  orbital  margin,  the  head 
is  thrown  back,  and  when  in  that  position,  the  lids 
are  frequently  opened  and  shut  until  every  part  is 
thoroughly  reached.  Heat  and  cold  can  also  be  ap- 
plied in  this  way. 

FOR  IRRIGATING  THE  EYE  before  and  after  opera- 
tions recourse  is  had  to  the  apparatus  commonly  em- 
ployed for  such  purpose. 


—  31  — 

In  applying  the  CAUTERY,  the  electric  form  is  to 
be  preferred  to  either  the  actual  or  that  of  Paquelin, 
for  many  reasons.  The  cautery  "  point  "  should  be  a 
delicate  one,  and  heated  white  hot. 

The  best  SPONGES  are  small  "  dabs  "  of  borated 
cotton,  which  are  thrown  away  after  being  used. 

OPERATION    PRELIMINARIES. 

The  patient's  person  and  clothing  should  be 
clean.  The  conjunctival  sac  is  well  irrigated  with 
boiled  boric  acid  solution,  and  the  eyelashes,  lids, 
eyebrows,  and  cheeks  thoroughly  scrubbed  first  with 
a  saturated  solution  of  boric  acid,  and  then  bathed 
with  a  1:5000  solution  of  corrosive  sublimate.  It  is 
assumed  that  the  instruments  have  all  been  placed  in 
a  95  per  cent,  solution  of  carbolic  acid  for  a  few  min- 
utes, and,  just  before  using,  are  transferred  to  a  boiled 
saturated  solution  of  boracic  acid,  or  to  boiled  water 
alone.  The  surgeon's  hands  should  be  well  washed 
with  hot  water  and  soap,  and  then  disinfected.  It  is 
superfluous  to  add  that  the  operator  should  not  be 
less  clean  than  the  patient.  A  well-lighted  (aseptic) 
room  is  chosen  for  the  operation.  The  patient  re- 
clines upon  an  operating  or  other  low  table,  with  the 
head  slightly  raised  and  steadied.  The  surgeon 
stands  in  front  or  behind,  as  he  wishes,  and  his  assist- 
ant stands  conveniently  by  in  charge  of  the  instru- 
ments. 


LESSQN  III. 

DISEASES  OF  THE  EYELIDS  AND  CONJUNCTIVA. 

Atropine  Irritation  —  Pterygium  —  Pinguecula  —  Lithiasis  — 
Blepharitis — A  "  Black  Eye" — Herpes  of  the  Lid — Stye 
or  Hordeolum — Chalazion  or  "Cyst  of  the  Lid — Lupus 
and  Epithelioma — Xanthelasma — Eutropion  and  Ectro- 
pion — Surgical  and  other  Treatment  of  these  Conditions 
— Hotz's  Operation — Ptosis — Lagophthalmos — Symble- 
pharon. 

The  more  important  diseases  of  the  conjunctiva 
have  been  exhaustively  treated  in  Mittendorf  s  work 
(see  Preface)  on  the  subject.  It  remains  for  me  to 
speak  of  some  additional  affections  of  that  membrane. 

ATROPINE    IRRITATION  AND  CONJUNCTIVITIS. 

i 

Atropine  and  its  salts  are  now  so  extensively  used 
that  it  is  important  to  recognize  a  not  uncommon 
idiosyncrasy  which  some  patients,  especially  old  peo- 
ple, exhibit.  It  sometimes  happens  that  even  after 
one  or  two  instillations  of  a  weak  solution  the  con- 
junctiva becomes  vascular  and  thickened;  a  muco- 
purulent  discharge  is  set  up  and  all  the  evidences  of 
an  acute  inflammation  show  themselves.  At  the  same 
time  the  skin  of  the  lids  appears  puffy,  shiny,  ex- 
coriated and  reddened.  These  symptoms,  due  as 
Treacher  Collins  has  shown,  to  the  local  irritant  ef- 
fects of  the  drug,  disappear  if  the  atropine  be  stopped 
and  zinc  ointment  be  applied  to  the  lids.  In  such 


—  33  — 

cases  also  duboisia  (23)  should  be  substituted  for  the 
atropine  and  boracic  lotion  (26)  used  as  a  collyrium. 

PTERYGIUM.  This  is  a  fleshy,  triangular,  hyper- 
trophy of  the  conjunctiva  with  its  apex  applied  to  the 
cornea  and  its  base  towards  one  of  the  canthi.  The 
origin  of  the  thickened  growth  is  a  curious  one. 
A  marginal  ulcer  of  the  cornea  (69)  forms,  and  in 
healing  incarcerates  a  minute  portion  of  the  ocular 
conjunctiva.  This  throws  the  latter  into  a  triangular 
fold  which  later  on  enlarges,  attaches  itself  to  the  cor- 
neal  tissue,  probably  by  proliferations  of  its  cellular 
constituents,  and  advances  towards  the  centre  of  the 
cornea,  which  it  sometimes  reaches. 

Treatment.  Excision  is  the  only  treatment  that 
accomplishes  anything.  The  corneal  attachment  of 
the  growth  should  be  carefully  and  evenly  dissected 
away  from  its  bed,  care  being  taken  to  avoid  injury 
to  the  deeper  tissues.  The  body  of  the  pterygium  is 
next  excised  in  its  entirety.  The  sound  conjunctiva 
having  been  undermined  is  stretched  over  the  vacant 
triangle  and  joined  by  sutures. 

PINGUECULA.  This  is  a  small  yellowish  eleva- 
tion on  the  conjunctiva  occurring  commonly  within 
the  inter-palpebral  slit  and  usually  on  the  nasal  side. 
It  is  an  inoffensive  growth,  is  composed  of  connective 
tissue,  seldom  attains  a  large  size  and  is  probably  the 
result  of  irritation  from  foreign  bodies.  Its  removal 
by  means  of  forceps  and  scissors  may  be  undertaken, 
if  considered  desirable. 


—  34   — 

LITHIASIS.  Chalky  degeneration  of  the  meibom- 
ian  secretions  (5)  may  often  be  noticed  as  white 
spots  on  the  conjunctiva  about  as  large  as  a  pin's 
head.  They  are  sometimes  surrounded  by  a  zone  of 
injected  blood  vessels,  and  may  be  a  source  of  con- 
siderable irritation.  If  productive  of  symptoms  they 
should  be  removed  under  cocaine  by  first  making  a 
small  incision  over  them  and  then  turning  out  the 
calcareous  particles  with  a  needle,  y 

BLEPHARITIS  MARGINALIS,  called  also  Tinea  tarsi, 
may  or  may  not  be  a  true  eczema  of  the  border  of  the 
lids.  It  is  a  very  chronic  affection,  lasting  often  for 
years,  and  is  frequently  accompanied  by  chronic  con- 
junctivitis. In  such  cases  both  affections  should  be 
treated  together  (M.  71).  The  chief  sign  of  the  dis- 
ease is  the  formation  of  crusts  or  scales  along  the  lid 
margin.  These  when  removed  expose  a  glazed,  red- 
dened or  moist  surface.  The  small  crusts,  which 
should  not  be  mistaken  for  eggs  of  pediculi  some- 
times laid  in  this  situation,  adhere  to  the  base  of  the 
cilia  which  often  become  stunted  and  broken.  After 
a  time  the  disease  affects  the  root-sheath  of  the  cilium, 
the  bulb  atrophies  and  the  lids  become  more  or  less 
destitute  of  lashes.  The  symptoms  are  not,  as  a  rule, 
urgent,  but  a  feeling  of  irritation  and  heat  in  the  eye, 
which  is  always  aggravated  by  exposure  to  wind  and 
sun,  is  usually  noticed.  After  a  time  the  eyes,  having 
lost  their  hairy  defenders,  suffer  from  the  entrance  of 
dust  and  other  foreign  bodies. 


—  35  — 

Treatment  should  first  of  all  be  directed  towards 
removal  of  the  crusts.  Very  few  patients  persevere 
in  this  endeavor  as  they  should,  and  it  is  accordingly 


FIG.  i. 

often  a  wise  measure  to  remove  with  the  forceps  (Fig. 
i)  every  eyelash  that  harbors  the  scabby  exudations. 
This  prevents  the  re-formation  of  the  crusts,  and 
gives  the  remedies  employed  a  better  chance  to  reach 
the  seat  of  the  disease  and  set  up  healthy  action  in 
the  parts  affected.  The  best  way  to  remove  the 
crusts  is  to  soak  them  well  with  a  hot  solution  of 
sodic  carbonate,  a  2  per  cent,  solution  diluted  with  its 
own  weight  of  boiling  water. 

After  the  removal  of  all  the  scabs,  a  one-half  per 
cent,  mixture  of  the  red  (or  yellow)  oxide  of  mercury 
with  cold  cream  should  be  thoroughly  rubbed  into 
the  edges  of  the  closed  eyelids.  This  may  be  done  in 
the  evening,  a  few  hours  before  retiring,  while  a  boric 
acid  lotion  (26)  should  be  applied  several  times 
during  the  day.  When  the  case  is  one  of  eczema, 
with  moist  crusts,  swelling  of  the  lids,  and  conjuncti- 
vitis, various  measures  have  been  advocated.  I  have 
seen  admirable  results  from  an  ointment  recommend- 


-  36  - 

ed  in  cases  of  eczema  by  Dr.  Zeisler  of  this  city.    The- 

formula  is: 

Resorcin 0.30     ^ 

Lac  sulphur. .. ..-..., i.oo     T^  >  > 

Lanoline s'.oo     A  >  •  i  ^ 

It  goes  without  saying  that  patients  suffering 
from  blepharitis  should  avoid  dust,  heat  and  wind,  as 
much  as  possible.  If  necessary,  they  should  wear 
protective  glasses  (30).  They  should  not  smoke 
themselves,  nor  allow  their  eyes  to  be  irritated  by  re- 
maining in  a  smoking-room.  The  general  health  is 
worth  looking  after;  indeed,  it  may  be  that  a  strum-' 
ous  diathesis  lies  at  the  bottom  of  the  disease. 

It  often  happens  that  a  blepharitis  is  perpetuated 
by  "  eye-strain  "  (R.  10).  Proper  glasses  should  in 
such  instances  be  ordered,  especially  if  there  be  any 
astigmatism  (R.  42)  present.  Whatever  the  treat- 
ment may  be,  a  complete  cure  is  not,  in  the  majority 
>of  cases,  to  be  expected  inside  of  several  months. 

ECCHYMOSIS  of  the  lids,  with  its  usual  accompani- 
ment of  subconjunctival  haemorrhage,  constitutes 
what  is  popularly  termed  a  "  black  eye."  Where  a 
definite  blood-clot  has  formed  within  the  palpebral 
tissues,  the  common  practice  of  incising  the  skin  and 
allowing  the  blood  to  escape  is  a  good  one.  Antisep- 
tic dressing  should  be  subsequently  applied.  The 
average  chemosed  eye  will  be  best  treated  with  an 
evaporating  lead  lotion  (28).  Unless  treatment  is 
resorted  to  within  two  days,  no  remedy  will  be  of  use. 


—  37  — 

It  is  then  best  to  cover  up  the  discoloration  with 
flesh-colored  paint.  It  will  pay  every  practitioner  to 
keep  some  water  colors  for  the  purpose.  No  produc- 
tion of  his  artistic  hand  will  be  more  appreciated  than 
that  which  disguises  such  a  noticeable  blemish. 

HERPES  OF  THE  LIDS  resembles  herpes  zoster 
elsewhere.  It  is  not  of  frequent  occurrence,  but 
ought  to  be  easily  recognized.  The  herpetic  vesicles 
are  disposed  about  one  or  more  cutaneous  branches 
of  the  fifth  nerve,  and  the  pain  accompanying  the 
disease  is  severe  and  of  a  neuralgic  character.  It 
may  also  attack  the  cornea,  conjunctiva,  and  even 
iris,  and  where  it  does  so  the  results  may  be  serious. 
Morphia  should  be  given  to  relieve  pain,  quinine  for 
its  specific  effect,  while  such  local  applications  as  hot 
belladonna  fomentations  are  useful. 

When  the  cornea  is  affected — as  in  a  case  recently 
seen  by  me — a  mixture  of  eserine  and  cocaine  (24) 
acts  very  well,  both  in  lessening  the  pain  and  subdu- 
ing the  corneal  inflammation.  -V" 

STYE  OR  HORDEOLUM.  This  is  a  very  common 
lid  affection  and  may  be  regarded  as  a  palpebral 
''boil."  When  it  occurs  near  the  outer  canthus  the 
cedema  of  the  lid  or  lids  is  often  considerable.  This 
is  probably  due  (Lang)  to  the  blocking  of  the  lym- 
phatic stream  which  empties  into  the  larger  channel 
near  the  ear.  In  children  there  is  usually  a  good 
deal  of  pain  and  sometimes  fever.  In  its  earliest 
stage,  before  pus  has  formed,  the  stye  may  sometimes 


be  aborted  by  pulling  out  the  eyelash  which  runs- 
through  it  and  painting  the  tumor  with  strong  tinc- 
ture of  iodine.  If  this  fails  the  point  of  a  Beer's 
knife— or  some  similar  instrument  — should  be  pushed 
into  the  centre  of  the  tumor  and  its  contents  evacu- 
ated. Subsequently  a  poultice  may  be  applied  and 
then,  in  a  day  or  so,  a  mild  mercuric  ointment  (26) 
should  be  rubbed  over  the  diseased  part.  Hordeola, 
like  boils  elsewhere,  are  liable  to  recur  and  when  they 
do  careful  search  should  be  made  to  detect  some  error 
of  refraction  (R.  22),  some  constitutional  cause,  or 
impropriety  of  diet,  likely  to  account  for  such  a  state 
of  things.  Frequently,  as  in  anaemic  girls,  a  course 
of  iron  and  fresh  air  is  what  is  chiefly  needed. 

EYELASH  IN  A  PUNCTUM.  Careful  inspection  of 
both  puncta  (4)  as  a  routine  observance  would  pre- 
vent one's  overlooking  this  little  accident,  but  the 
possibility  of  its  happening  should  always  be  borne 
in  mind.  Until  removed  it  creates  a  good  deal  of 
disturbance  as  well  actual  conjunctivitis. 

CHALAZION.     Cyst  of  the  lid.     This  is  a  smalL 

' 

painless,  hard,  slow-growing  and  slightly  movable 
tumor  imbedded  in  the  tarsal  cartilage.  It  is  a 
"retention  cyst,"  being  generally  produced  by  the 
obstruction  of  a  meibomian  (5)  tubule.  The  contents- 
are  usually  cheesy,  but  the  tumor  sometimes  resembles 
a  fibroma  in  hardness.  Local  applications  do  little  or 
no  good.  As  the  tumor  generally  "points"  towards  the 
conjunctival  surface  of  the  lid  it  is  best  to  evert  the 


—  39  — 

latter  and  empty  the  cyst  in  that  direction.    Some  sur- 
geons use  a  special  clamp  for  this  purpose  (see  Fig.  2.) 


FIG.  2. — SNELLEN'S  LID  CLAMP. 

In  all  cases  the  parts  should  be  anaesthetized  by  means 
of  a  four  per-cent.  solution  of  cocaine.  The  clamp  hav- 
ing been  applied,  the  lid  is  everted,  an  incision  made  the 
whole  length  of  the  tumor  (whose  position  is  indicated 
by  a  purplish  discoloration  of  the  mucous  membrane), 
and  the  cyst  contents  evacuated  by  means  of  a  small 
scoop  or  the  end  of  a  director.  In  large  chalazia  it  is 
well  to  arm  a  probe  with  a  little  cotton  wool,  and  brush 
out  the  cavity  with  a  drop  of  strong  nitrate  of  silver 
solution  (4  or  5  per  cent.).  This  will  effectually  pre- 
vent their  return.  The  patient  should  always  be 
warned  of  the  fact  that  after  an  operation  for  the  re- 
moval of  the  contents  of  a  meibomian  cyst  the  vacuum 
is  filled  with  a  blood  clot  and  the  tumor  feels  larger 
than  ever.  In  a  few  days,  however,  absorption  begins 
and  the  tumor  gradually  disappears. 

Tarsal  cysts  may  be  produced  by  eye  strain  (R.  10) 
blepharitis  (34),  and  other  diseases,  local  and  general. 
When  they  occur  and  are  multiple  this  fact  should  be 
borne  in  mind. 


—  40  — 

RODENT  ULCERS,  EPITHELIOMA  AND  LUPUS  affect 
the  lids  as  elsewhere.  In  all  three  diseases  prompt 
and  early  treatment  by  the  actual  cautery  or  other 
caustics  will  prove  effectual.  Later  on  a  plastic  oper- 
ation will  be  necessary. 

XANTHELASMA  is  a  sufficiently  common  affection 
of  the  lids  and  is  almost  exclusively  confined  to  the 
female  sex — especially  those,  as  Meyer  says — who 
suffer  from  migraine  and  affections  of  the  liver.  It 
forms  an  irregular  yellowish  patch  or  patches  and  is 
made  up  chiefly  of  fibrous  tissue  — not  fat.  It  is  a 
harmless  growth,  but  may  be  removed  if  the  patient 
objects  to  its  presence. 

ENTROPION. — This  is  a  term  which  indicates  a 
turning  in  of  the  edge  of  the  lid.  It  may  result  from 
contraction  of  the  orbicularis  in  old  people  with 
flabby  lids,  from  burns,  or  from  other  injuries,  but  is 
almost  always  caused  by  granular  lids  (M.  45).  This 
last  disease  first  produces  scarring  (and  contraction) 
of  the  mucous  membrane,  and  later  on,  irregular 
atrophy  and  consequent  incurvation  of  the  tarsus. 
The  eyelashes  are  secondarily  affected,  and  some  of 
them  turn  down  (4),  touch  and  irritate  the  cornea. 
If  there  be  two  regular  rows  of  cilia,  one  is  very  apt, 
for  a  while  at  least,  to  retain  its  outward  curve,  while 
the  other  curves  in  upon  the  sensitive  globe.  Such  a 
condition  of  affairs  is  termed  DISTICHIASIS.  When 
the  curvation  of  the  lashes  is  irregular,  or  if  but  a  few 
of  them  are  thus  affected,  the  term  TRICHIASIS  is  em- 


ployed  to  describe  it.  In  most  of  these  cases  the 
situation  is  made  worse  by  a  shortening  of  the  inter- 
palpebral  aperture;  the  lids  are  too  closely  applied  to 
the  eyeball;  the  patient  cannot  separate  them  widely 
enough,  and  all  the  symptoms  are  aggravated  thereby. 
This  may  be  remedied  by  a  simple  operation  called 
CANTHOPLASTY,  and  it  may  be  performed  alone  or 
as  an  adjunct  to  other  operations  upon  the  lids  or 
lashes.  The  external  commisure  is  cut  through  in 
the  horizontal  line  and  directly  outwards  with  a  pair 
of  straight  scissors.  The  sharp-pointed  blade  of  the 
latter  is  entered  underneath  the  lids  at  the  outer  can- 
thus,  and  the  skin  wound  made  a  few  millimetres 
longer  that  in  the  mucous  membrane.  The  subcu- 
taneous injection  of  a  few  drops  of  cocaine  (4  per 
•cent,  solution)  will  render  this  a  comparatively  pain- 
less operation.  The  conjunctival  edges  are  now  well 
separated  from  the  underlying  tissues,  and  with  three 
stitches  are  evenly  joined  to  the  margin  of  the  skin 
wound.  An  antiseptic  lotion,  and  the  removal  of  the 
stitches,  in  from  four  days  to  a  week,  complete  the 
cure.  If  the  entropion  be  well  marked,  an  efficient 
operation  constitutes  the  best  means  of  remedy- 
ing all  the  evils  attendant  upon  that  condition, 
but  in  many  cases  it  will  suffice  to  do  a  canthoplasty 
and  destroy  a  few  troublesome  cilia.  Do  not,  how- 
ever, temporize  by  pulling  them  out  unless  the  patient 
positively  refuses  to  undergo  an  operation.  In  that 
•case  remember  it  is  the  fine,  short,  and  colorless  hairs, 


—  42   — 

that  do  most  mischief,  and  are  just  the  ones  most 
likely  to  be  overlooked,  unless  one  have  sharp  eyes  or 
use  a  lens  (9). 

EPILATION  is  practiced  with  special  cilia  forceps- 
having  broad  and  smooth  ends  (Fig.  i.). 

It  is  best  to  destroy  the  incurving  hairs  of  trichi- 
asis,  if  they  are  not  too  numerous,  by  one  or  both  of 
the  following  measures:  ist.  Michel's  method,  electro- 
lysis. A  platinum  needle  is  connected  with  the  nega- 
tive pole  of  a  2o-volt  battery,  and  plunged  accurately 
into  the  ciliary  follicle,  the  positive  pole  being  grasped 
by  the  patient.  The  action  of  the  battery,  as  evi- 
denced by  the  disengagement  of  hydrogen  from  the 
neighborhood  of  the  follicle,  should  be  kept  up  for  do- 
seconds.  Even  with  a  previous  injection  of  cocaine 
this  is  a  painful  procedure.  2d.  Snellen's  method. 
Thread  a  small  and  sharp  needle  with  both  ends  of  a 
fine  silk  thread.  Enter  the  former  at  the  base  of  a 
cilium,  push  it  underneath  the  palpebral  skin,  and 
bring  it  out  six  or  eight  mm.  from  the  lid  margin.  As 
the  doubled  thread  is  drawn  through,  ensnare  the  lash 
and  draw  it  bodily  into  the  substance  of  the  lid. 

Hotzs  operation  for  entropion. — When  from  one 
cause  or  another  (usually  resulting  from  long  stand- 
ing trachoma  or  granular  lids)  the  preceding  meas- 
ures are  found  or  judged  to  be  inadequate  for  the 
cure  of  the  entropion  and  triachiasis,  a  more  radical 
operation  is  necessary.  A  volume  might  be  devoted 
to  a  description  all  of  those  that  have  been  from  time: 


—  43  — 

to  time  devised.  Taken  all  in  all,  that  of  Hotz  is  to 
be  preferred.  He  aims  to  make  the  lower  edge  of 
the  lid  wound  adhere  to  the  upper  edge  of  the  tarsus 
and  so  by  a  sort  of  leverage  action  draw  the  palpebral 
border  with  its  incurved  cilia  outward. 

Ether  or  chloroform  is  given  and  a  lid  spatula 
may  or  may  not  be  used.  An  assistant  now  draws  up 
and  holds  the  skin  of  the  (upper)  lid  firmly  against 
the  brow  whil«.  the  operator  puts  it  on  the  stretch  with 
forceps  in  an  opposite  direction.  An  incision  is  made 
horizontally  from  a  point  2  min.  above  the  inner  can- 
thus  to  a  corresponding  point  above  the  outer  com- 
missure. If  the  skin  be  now  left  free  this  incision  will 
be  found  to  be  curved  and  to  correspond  with  the 
superior  edge  of  the  tarsus.  The  lower  edge  of  the 
wound  is  now  drawn  down  with  forceps  and  the  sur- 
geon dissects  some  of  the  fibres  of  the  orbicularis 
from  the  upper  third  of  the  tarsus.  The  bleeding 
having  stopped,  three  or  four  sutures  are  inserted  by 
a  curved  needle,  first  into  the  upper  edge  of  the 
wound,  then  through  the  upper  edge  of  the  tarsus 
and  some  of  the  tarso-orbital  fascia  just  above  it,  and 
finally  through  the  lower  margin  of  the  skin  wound. 
The  bleeding  having  stopped  and  the  wound  cleared 
of  clots  and  well  irrigated,  the  ends  of  the  thread  are 
firmly  tied  together  binding  both  edges  of  the  incision 
to  the  upper  margin  of  the  tarsal  plate.  lodoform  or 
other  antiseptic  dressing  is  now  applied  and  the 
stitches  should  be  removed  in  two  days  or  on  the  ap- 
proach of  suppuration. 


—  44  — 

ECTROPIUM.  In  old  people  when  a  portion  of 
the  musculus  orbicularis  becomes  atrophied,  the 
lower  lid  is  especially  prone  to  resign  its  close  applica- 
tion to  the  globe  and  sinks  down,  carrying  with  it  the 
punctum  lacrymale.  As  a  consequence  the  tears  flow 
over  the  cheek  and  produce  excoriation  of  the  skin 
and  edge  of  the  lid.  This  in  its  turn  brings  on 
oedema  of  the  parts,  chronic  conjunctivitis  and  finally 
spasm  of  the  remaining  orbicularis  fibres  so  that  the 
lid  is  everted.  This  particular  form  of  the  disease  is 
terned  senile  ectropium.  Scars  from  burns  and  wounds 
may  also  bring  about  the  same  condition,  but  the 
great  majority  of  examples  of  entropium  are  the  re- 
sult of  muscular  spasm  caused  by  oedema  of  the  pal- 
pebral  conjunctiva. 

The  Treatment  should  be  directed  first  towards 
the  removal  of  the  cause  of  the  trouble.  The  excision 
of  cicatricial  tissue  with  transplantation  of  skin  will 
afford  ample  opportunity  for  the  exercise  of  the  sur- 
geon's best  skill,  and  the  rules  to  be  observed  do  not 
differ  from  those  in  vogue  in  other  skin  and  mucous 
membrane  regions  elsewhere.  Do  not  forget  that 
pieces  of  skin  have  been  removed  en  masse  from  the 
arm  and  other  situations  and  have  taken  kindly  to 
their  new  position  in  the  facial  region.  The  value 
or  necessity  of  the  pedicle  has  probably  been  over- 
rated hitherto.  For  muscular  entropium  many  opera- 
tive measures  have  been  employed.  One  of  the  best 
of  these — easy  to  perform — is  that  of  Snellen.  A 


—  45  — 

double-needled  silk  thread  is  used,  one  needle  being 
entered  where  the  everted  conjunctiva  is  most  promi- 
nent and  brought  out  through  the  skin  2  cm.  below 
the  lower  lid  margin.  The  other  needle  is  passed  in 
the  same  way,  the  points  of  exit  in  the  skin  being 
about  i  cm.  apart.  Traction  is  now  made  upon  the 
threads,  the  mucous  membrane  is  pulled  down  while 
the  palpebral  margin  is  assisted  into  place.  The  ends 
of  the  thread  are  tied  over  a  piece  of  rubber,  to  pro- 
tect the  skin.  In  the  meantime  any  oedema,  con- 
junctivitis, or  other  lid  affection  should  be  treated,  in 
the  hope  that  the  patient  will  be  able  to  get  along 
without  the  sutures — two  or  more  of  which  may  be 
required. 

In  spite  of  this  and  similar  devices  a  cutting 
operation  may  be  needed.  That  recommended  by 
Adams  is  a  good  one,  but  to  be  successful  and  not  to 
leave  a  deficiency  at  the  border  of  the  lid  or  an  ugly 
scar  in  the  skin  very  accurate  coaptation  of  the  edges 
of  the  wound  should  be  secured. 

A  piece  of  the  lid  in  its  whole  thickness  is  re- 
moved with  the  mucous  membrane,  as  pictured  in 
Fig.  3.  The  edges  are  then  carefully  brought  together 
and  dressed. 

PTOSIS. — Drooping  of  the  upper  lid  may  result 
from  a  number  of  causes.  Of  these  the  commonest 
is  paralysis  of  the  third  nerve  (137),  which  supplies  the 
levator  palpebrse.  Next  in  order  of  causation  come 
thickening  and  increased  weight  of  the  lid  from  dis- 


_  46  - 

eases  (chronic  inflammation,  trachoma,  etc.),  con- 
genital deficiency  of  the  elevator  muscle,  and  (when  it 
is  bilateral)  finally  wounds  and  adhesions.  Apart 
from  the  deformity,  which  is  very  noticeable,  the  fall- 
ing of  the  lid  over  the  pupil  directly  interferes  with 
vision. 


FIG.  3. 

Treatment.  -After  electricity  and  other  appro- 
priate treatment  have  failed,  this  condition  is  rem- 
edied by  an  operation.  The  usual  method  is  to  excise 
a  horizontal  oval-shaped  piece  of  skin  from  the  lid. 
To  remove  enough  to  allow  of  vision,  and  yet  not  so 
much  as  to  prevent  closure  of  the  eye  during  sleep,  is 
the  problem.  A  preliminary  observation  should  be 
made  by  pinching  up  the  palbebral  skin  with  a  pair 
of  forceps,  and  thus  judging  of  the  amount  to  be  re- 


—  47  — 

moved.  Subsequently  the  edges  of  the  wound  are 
brought  together  by  sutures. 

LAGOPHTHALMOS. — This  is  the  condition  opposed 
to  ptosis,  wherein,  from  paralysis  of  the  orbicularis, 
the  patient  is  unable  to  close  the  eyes.  Literally 
translated,  it  means  "  hare  eye,"  as  that  animal  is  said 
to  sleep  with  its  eyes  open.  The  diagnosis  is  easily 
made  if  the  patient  be  told  to  shut  his  eyes.  When 
the  disease  is  one-sided,  as  it  commonly  is,  these 
efforts  are  productive  of  a  curious  result,  viz.:  the 
eye  of  the  affected  side  assumes  the  position  it  occu- 
pies during  sleep,  and  is  plainly  seen  to  roll  up  under 
the  unclosed  lid.  This  is  a  fortunate  position,  as  it 
serves  to  protect  the  cornea  from  the  dessicating 
effects  of  the  atmosphere,  and  from  injury  by  foreign 
bodies.  Lagophthalmos  is  almost  always  produced 
by  paralysis  of  the  portio  dura,  but  it  may  also  result 
from  anything  which  brings  about  undue  projection 
of  the  eyeball,  as  staphyloma  corneae  (76),  extreme 
myopia/ Graves'  disease  (122),  orbital  (121)  and  intra- 
ocular growths. 

Treatment. — In  paralytic  cases,  and  in  some  of 
those  due  to  the  other  causes  mentioned,  a  simple 
operation,  termed  tarsoraphy,  will  be  useful.  By 
means  of  it  the  interpalpebral  slit  is  both  shortened 
and  narrowed. 

A  short  strip  of  skin,  the  length  of  which  will  be 
determined  by  the  effect  desired,  is  removed  from  the 
margins  of  the  lids  at  the  outer  canthus.  The  cilia 


-  48  - 

with  their  bulbs  are  included  in  the  excision,  and  the 
pared  edges  are  sewed  together.  This  operation  will 
not  be  undertaken  until  the  effects  of  remedies 
directed  towards  the  removal  of  the  cause  of  the 
lagophthalmos  have  been  tried. 


FIG.  4. 

SYMBLEPHARON. — This  is  the  term  applied  to  the 
abnormal  union  of  the  ocular  with  the  palpebral  con- 
junctiva. It  may  be  partial  or  total,  and  is  most  fre- 
quently produced  by  escharotics,  such  as  lime,  molten 
lead,  acids  or  strong  alkalies,  introduced  into  the 
conjunctival  sac.  Adhesion  does  not  occur  for  several 
days  or  weeks  after  the  accident,  and  it  is  extremely 
difficult  to  prevent  it. 

Treatment. — In  slight  cases  the  cicatricial  bands 
are  to  be  cut  through,  and  the  edges  of  the  healthy 
conjunctiva  united  over  the  raw  surface  by  sutures. 
In  more  extensive  cases,  after  separation  of  the  con- 
junctival surfaces,  one  or  both  wounds  may  be  covered 
by  conjunctival  flaps  or  with  mucous  membrane  trans- 
ferred from  the  lip  or  from  the  rabbit's  conjunctiva. 


LESSON  IV. 

DISEASES  OF  THE  LACHRYMAL  APPARATUS. 

Epiphora — Lachry mation  —  Dacryocystitis  —  Lachrymal  Ab  - 
scess — Slitting  Up  the  Canaliculus — Passing  the  Nasal 
Probe — Treatment  of  Lachrymal  Obstruction  by  the 
Syringe  of  Meyer  or  Anel. 

EPIPHORA  is  the  name  usually  employed  to 
designate  a  flow  of  tears  over  the  lower  lid  margin. 
LACHRYMATION  refers  more  particularly  to  an  increase 
in  the  supply  of  tears.  Anything  which  interferes 
with  the  drainage  (5)  of  the  external  eye  will  pro- 
duce epiphora;  any  cause  which  stimulates  the  forma- 
tion of  tears  produces  lachrymation.  Among  other 
causes  of  epiphora, besides  lachrymation, maybe  men- 
tioned: (i)  Those  that  produce  misplacement  of  the 
puncta  (4),  such  as  surgical  and  other  wounds  in  the 
neighborhood,  paralysis  of  the  facial  nerve  (by  which 
the  orbicularis  loses  its  tone),  and  laxness  of  the  pal- 
pebral  tissues  dependent  upon  senile  changes;  (2) 
Obstruction  at  some  point  in  the  lachrymal  canal  or 
nasal  duct.  The  latter  is  the  commonest  and  most 
important  cause  of  epiphora,  which  will  hereafter  be 
considered  merely  as  a  symptom  of  this  class  of  dis- 
eases. 

DACRYOCYSTITIS. — There  is  a  certain  resemblance 
between  inflammation  of  the  urethra  and  the  same 
affection  of  the  tear  passages.  Both  usually  start 


—  50  — 

from  infection  supplied  from  without — in  the  case  o; 
the  latter  from  chronic  maladies  of  the  lids,  such  as 
blepharitis  (34),  trachoma  (M.  45),  diseases  of  the 
nose  and  nasal  duct;  both  tend  to  the  formation  of 
pus  and  to  stricture  of  the  canal;  and  both  have, gen- 
erally speaking,  the  same  treatment.  When  the  mu- 
cous lining  of  the  canaliculus  and  tear  sac  becomes 
inflamed,  it  is  called  dacryocystitis.  The  acute  dis- 
ease shortly  passes  into  the  chronic  stage,  or  it  is 
chronic  from  the  beginning,  and  we  have  as  symp- 
toms of  the  latter  mainly  epiphora,,  increased  by 
wind  and  sun,  and  the  hypersecretion  of  mucus  mixed 
with  some  pus.  For  a  time  these  abnormal  secretions 
are  carried  along  the  nasal  duct  into  the  nose,  but 
after  a  while  the  whole  mucous  membrane  of  the 
canaliculus,  sac,  and  nasal  duct  becomes  involved, 
distension  of  the  sac  takes  place,  and  the  muco-pus 
regurgitates  through  one  or  both  puncta  into  the  con- 
junctival  sac,  and  may  be  seen  as  flocculi  floating  in 
the  tear  drops.  In  all  such  cases,  firm  pressure  (5) 
should  be  made  over  the  region  of  the  sac  at  the 
inner  canthus.  Even  before  the  internal  enlargement 
becomes  so  pronounced  as  to  show  itself  as  a  decided 
swelling  in  such  region,  this  procedure  will  cause  the 
muco-purulent  fluid  to  issue  from  one  or  both  puncta. 
This  settles  the  point,  and  proves  at  least  the  exist- 
ence of  an  obstruction  in  or  below  the  lachrymal  sac. 
The  obstruction  may  be  due  merely  to  swelling  of 
the  chronically  inflamed  mucous  membrane,  or  it  may 


mean  an  organic  stricture  closely  resembling  an  ure- 
thral  stricture.  The  practitioner  will  find  the  follow- 
ing a  useful  guide  to  diagnosis  in  these  cases:  When 
the  sac  is  enlarged,  and  pus  can  be  squeezed  out  of  the 
puncta,  an  organic  obstruction  (stricture)  is  present;  but 
if  there  be  little  or  no  cystic  swelling  and  the  secretion  is 
mostly  mucus,  the  obstruction  is  a  swollen  mucous  mem- 
brane. 

In  the  first  instance  the  introduction  of  probes, 
combined  with  slitting  up  one  of  the  canaliculi,  will  be 
the  only  effective  treatment.  In  the  latter  instance — 
in  the  so-called  mucocele — washing  out  the  lachrymal 
tract  (55)  through  one  of  the  puncta  will  be  efficacious. 

LACHRYMAL  ABSCESS. — A  distended  sac  in  these 
chronic  cases  is  always  liable  to  inflame  and  form  an 
abscess.  When  that  occurs,  an  erysipelatous  blush 
surrounds  the  seat  of  the  disease,  there  is  consider- 
able swelling  of  the  lid  and  sometimes  of  the  face, 
while  the  pain  may  be  severe.  If  left  to  itself,  the  pus 
points  underneath  the  skin  about  the  sac,  the  abscess 
opens  and  leaves  an  ugly  fistula,  which  is  often  diffi- 
cult to  heal. 

Treatment.  If  seen  early  either  the  lower  or  the 
upper  canaliculus  should  be  slit  up  with  a  knife  used 
for  the  purpose,  and  a  probe  passed  through  the  stric- 
ture into  the  nose.  This  is  usually  sufficient  to  stay 
the  further  progress  of  the  disease.  If  seen  late,  when 
the  skin  over  the  abscess  is  very  thin,  it  is  better  to 
•  open  the  latter,  reduce  the  spelling  by  appropriate 


—  52  — 

applications  and  attend  to  the  stricture  subsequent- 
ly.    The  scar  left  is  insignificant. 


G.TIEMWW  1  O) 

FIG.  5. 

SLITTING  UP  THE  CANALICULUS  is  performed 
with  the  knife  (Fig.  5)  before  referred  to,  as  follows: 
If  ambidextrous  the  surgeon  always  sits  in  front  of 
his  patient.  If  he  wishes  to  use  his  right  hand  in 
every  case  he  will  stand  behind  the  patient's  head 
when  he  operates  on  the  right  eye;  the  left  canaliculi 
are  more  easily  reached  from  the  front.  To  open  the 
lower  canaliculus — the  usual  one — the  punctum  is 
everted  and  the  point  of  the  knife,  edge  upward,  en- 
tered at  right  angles  to  the  lid  margin.  The  palpeb- 
ral  skin  is  now  drawn  towards  the  outer  canthus  with 
the  disengaged  hand  and  the  handle  of  the  knife  de- 
pressed until  it  is  almost  horizontal.  It  is  now  pushed 
towards  the  sac  until  its  nasal  wall  is  felt.  Keeping 
its  point  steadily  in  that  position  the  handle  of  the 
knife  is  partially  rotated  so  that  the  edge  of  the  blade 
now  looks  upwards  and  slightly  inwards.  The  han- 
dle is  now  carried  up  and  slightly  past  the  median 
line,  cutting  through  the  wall  of  the  canal  within  the 
lid  margin,  and  is  again  rotated  to  be  used  as  a  cut- 
ting probe,  and  passed  down  into  the  nasal  duct  as 
described  below.  An  anaesthetic  is  not  usually  neces- 
sary, and  bleeding  from  the  nose  should  follow  the- 


—  53  — 

operation,  showing  that  an  open  communication  now 
exists  between  the  conjunctival  sac  and  the  meatus. 
Lachrymal  probes  may  be  passed  after  24  hours. 

PASSING  THE  PROBE.  Stricture  of  the  nasal  duct 
is  as  difficult  to  cure  as  is  the  urethral  stricture  and  it 
may  be  necessary  to  pass  probes  (bougies)  two  or  three 
times  a  week  or  oftener,  for  several  months.  I  am 


FIG.  6. 

greatly  in  favor  of  teaching  the  patient  to  do  this 
himself  and  to  instruct  him  to  keep  it  up  at  increasing 
intervals  for  a  year  or  more.  The  difficulty  is  that 
the  sufferer  getting  relief  from  an  operation  and  the 
subsequent  half  dozen  probings  administered  by  the 
surgeon,  gives  up  treatment  and  the  disease  relapses. 
The  probes  used  are  of  all  sizes  and  shapes.  Those 
-devised  by  Bowman,  made  of  silver,  (Fig.  6)  and 


—  54  — 

numbered  from  i  to  8  answer  most  purposes. . 
Passed  along  the  opened  canaliculus  to  the  posterior 
wall  of  the  sac,  with  the  lid  margin  kept  on  the 
stretch,  the  probe  is  elevated  and  carried  slightly  past 
the  median  line  until  it,  while  almost  touching  the 
brow,  points  downwards,  outwards,  and  slightly  back- 
wards. It  should  now  pass,  without  employing  undue 
force,  into  the  nose.  As  large  a  size  as  possible 
should  be  used  and  the  probing  should  be  done  daily, 
while  the  patient  should  take  lessons  in  passing  the 
instrument  himself.  Care  must  always  be  observed 
not  to  make  a  false  passage.  If  persevered  in,  a  cure 
of  lacrymal  obstruction  when  not  due  to  diseases  of 
the  bone  (osteomata,  syphilis  and  the  like)  can  be 
confidently  expected.  With  the  observance  of  all 
precautions  a  fine  probe  may,  in  the  manner  that  the 
canaliculus  knife  is  entered  (52),  be  passed  through 
the  punctum  along  the  canaliculus  and  into  the  nasal 
duct.  This  was  Becker's  plan  and  in  cases  of  muco- 
cele  or  slight  stricture  it  has  much  to  recommend  it. . 


FIG.  7. 

Ariel's  or  Meyer's  syringe.  A  canaliculus  once 
opened  in  the  manner  above  described  seldom  or 
never  closes,  so  that  the  natural  drainage-function  of 
the  parts  is  destroyed.  The  operation  should  not  on  . 


--  55  — 

that  account  be  lightly  undertaken.  For  most  cases 
of  mucocele— as  before  stated — systematic  syringing 
of  the  passage  from  punctum  to  nasal  meatus  is  suffi- 
cient in  many  instances  to  bring  about  a  cure  without 
having  recourse  to  probing  or  the  cutting  operation. 
In  any  case,  however,  treatment  of  the  lining  mem- 
brane of  the  tear  passage  is  indicated.  For  this  pur- 
pose boric  acid  lotion,  with  the  addition  of  zinc  sul- 
phate, i  grain  to  the  fluidounce,  makes  a  very  good 
astringent  application  and  is  much  used.  Some  sur- 
geons prefer  oily  preparations — such  a  prescription  as 
this,  for  example: 

Menthol 0.50 

Benzoinol 10.00 

Whatever  be  the  remedy,  a  syringe  such  as  is 
shown  in  Fig.  7  is  used.  The  sac  contents  are  first 
squeezed  out,  the  point  of  the  syringe  entered  at  the 
punctum,  passed  along  to  the  sac,  as  in  probing  (53), 
directed  downward  and  the  nasal  duct  flushed  into 
the  nose.  If  the  punctum  be  too  small  for  the  en- 
trance of  the  syringe  point,  it  must  first  be  dilated 
with  a  fine  Bowmans'  probe.  Cocaine  may  be  ap- 
plied as  a  preliminary  to  this  procedure,  but  the  pain 
is  inconsiderable.  In  all  such  cases  any  accompany- 
ing conjunctival  or  nasal  disease  should  by  no  means 
be  neglected.  Lang  advises  that,  as  in  thp  treatment 
by  probing,  the  patient  be  taught  to  continue  the 
lacrymal  "flushings"  at  home,  with  a  fine  point  at- 
tached to  a  rubber  tube  and  bulb. 


LESSON  V. 

DISEASES    OF    THE    CORNEA    AND    SCLEROTIC. 

Arcus  Senilis — Keratitis — Phlyctenular  Keratins  —  Foreign 
Bodies  in  the  Cornea — Interstitial  Keratitis — Punctate 
Keratitis — Ulcers  of  the  Cornea — Spreading  and  Non- 
spreading  Ulcers — Hypopyon  and  Onyx — Paracentesis 
of  the  Anterior  Chamber — The  Use  of  the  Cautery — 
Senile  Ulcer — Opacities  of  the  Cornea — Nebula,  Macula 
and  Leucoma — Staphyloma  Anterius — Tatooing  the 
Cornea — Scleritis  and  Episcleritis 

ARCUS  SENILIS. — The  cornea  retains  its  central 
transparency  in  a  wonderful  way  until  quite  old  age 
and  it  rarely  happens,  except  as  the  result  of  injury 
or  inflammation,  that  vision  is  interfered  with  in  con- 
sequence of  degeneration  of  its  tissues.  Marginal 
changes  are  not  uncommon.  The  most  frequent  of 
these  is  the  so-called  arcus  senilis,  although  it  is  not 
necessarily  a  sign  of  senility.  It  presents  itself  in  the 
form  of  a  narrow  grayish  crescent,  placed  above  or 
below,  or  it  may  extend  entirely  round  the  cornea. 
It  is  composed  of  corneal  cells  which  have  undergone 
a  true  fatty  metamorphosis. 

Inflammation  of  the  cornea  is  termed  KERATITIS. 
The  inflammatory  process  may  affect  the  external 
epithelium'and  superficial  layers  or  it  may  extend  as 
in  ulcer  (70),  and  parenchymatous  keratitis  (66),  to 
the  true  tissue  of  the  cornea.  Finally,  it  may  be  con- 


—  57  — 

fined  chiefly  to  the  endothelium — the  membrane  of 
Descemet  ^69). 

PHLYCTENULAR  KERATITIS. — This  is  substan- 
tially the  same  disease  that  one  finds  in  the  conjunctiva 
[M.  3.]  and  the  little  phlyctenulae  or  ulcers  which 
characterize  it  are  sometimes  seen  affecting  both 
cornea  and  conjunctiva. 

In  this  little  colored  child  *  we  have  a  good  ex- 
ample of  what  is  commonly  known  as  phlyctenules  of 
the  cornea.  Her  mother,  who  comes  with  her,  gives 
the  following  account  of  the  case: 

Three  weeks  ago  the  left  eye  began  to  water  a 
little,  and  the  child  complained  that  bright  light  hurt 
it.  Simultaneously  with  the  discharge  from  the  eye 
the  nose  began  to  run.  Both  these  symptoms  got 
gradually  worse  until  about  ten  days  after  they  were 
first  noticed;  the  right  eye  and  the  right  nostril  also 
became  affected,  and  began  to  discharge  a  watery 
fluid.  The  child  henceforth  kept  herself  shut  up  in  a 
dark  room  or  curled  herself  up  in  a  corner,  fearful 
lest  the  light  should  get  to  her  eyes.  Her  appetite 
began  to  fail,  she  took  no  part  in  her  usual  amuse- 
ments, and  sometimes  complained  of  pain  in  the  eyes. 
Just  now,  as  we  examine  her  critically,  we  find  that 
the  child  has  her  face  buried  in  the  angle  formed  by 
her  bent  arm,  which  she  leans  upon  her  chair.  Dis- 
engaging her  face,  we  find  the  eyelids  somewhat 

*  Clinical  Studies  of  the  Eye.  The  author's  paper  in  the 
.North  American  Practitioner  for  Sept.,  i8qo. 


-  58  - 

shiny  and  swollen.  Both  they  and  the  cheeks  are 
dotted  over  with  moist  eczematous  patches.  The 
upper  lip  is  swollen,  eczematous,  and  covered  with 
nasal  discharge.  Pursuing  our  investigation  still 
further,  we  find  the  moist  crusts  of  acute  eczema 
behind  the  right  ear,  and  there  is  a  thin  discharge 
from  the  external  meatus.  The  left  ear  is  un- 
affected. The  ear  trouble  has  been  there,  the 
mother  says,  for  over  a  month.  The  child  now 
resists  any  attempt  to  open  the  lids,  which  are  kept 
tightly  closed.  She  will  show  us  her  tongue,  which 
has  a  white  coat.  Formerly  the  term  photophobia  was 
believed  to  give  a  proper  description  of  the  condition 
present,  but  it  is  easy  to  show  that  there  is  no  true 
fear  of  the  light.  We  shall  put  a  few  drops  of  a  3 
per  cent,  solution  of  cocaine  into  the  little  one's  eye, 
and  although  the  effect,  so  far  as  the  retina  is  con- 
cerned, will  be  rather  to  irritate  the  latter  (by  dilating 
the  pupil  and  admitting  more  light  to  the  eye),  still  a 
decided  amelioration  of  the  supposed  photophobia 
soon  takes  place.  I  now  do  this,  putting,  at  short  in- 
tervals, several  drops  into  both  eyes,  and  while  we  are 
waiting  for  it  to  produce  its  characteristic  effects,  we 
will  proceed  to  discuss  this  and  other  matters  con- 
nected with  the  disease.  The  cocaine  relieves  the 
photophobia  (so-called)  by  numbing  the  terminal  fila- 
ments of  the  fifth  nerve — the  sensitive  nerve  of  the 
cornea.  Iwanhoff  thinks  the  corneal  distress  is  caused 
by  the  irritation  of  the  delicate  nerve  filaments,  pro- 


—  59  — 

duced  by  wandering  leucocytes  as  they  enter  the  cor- 
neal  tissue  at  the  limbus  and  travel  forward  to  form 
nests  of  cells  immediately  underneath  the  superficial 
epithelial  layer.  These  round  cells  in  their  passage 


.1,11.-      £ 


FIG.     8. 


A.  Anterior  Epithelium. 

B.  Bowman's  Membrane. 

C.  Substantia  Propria. 

D.  Descemet's  Membrane. 


E.  Endothelium. 

F.  Phlyctenule, 

G.  Nerve  Filament  pressed  upon 

by  emigrant  cells. 


irritate  the  minute  nerve  branches  which  ramify 
throughout  the  cornea,  and  give  rise  to  reflex 
spasms  of  the  orbicularis  palpebrarum.  The  accom- 
panying diagram  (Iwanhoff)  will  explain  this  pretty 


—  6o  — 

theory,  and  help  to  give  one  an  idea  of  the  patho- 
logical histology  of  this  disease  and  indicate  what  a 
phlyctenule  really  is.  Phlyctenular  keratitis  occurs 
mostly  in  children  out  of  health — often  in  strumous 
children — and  very  often,  as  we  have  seen  to-day,  in 
those  who  are  subject  to  attacks  of  acute  eczema.  In 
fact  it  is  regarded  by  some  as  a  true  corneal  eczema. 
At  first  the  phlyctenula  merely  shows  (see  diagram)  as 
a  minute  subepithelial  deposit  of  round  cells — a  slight 
infiltration  or  elevation  on  the  corneal  surface.  This 
soon  breaks  through  the  overlying  epithelium,  and  we 
have  a  true  ulcer.  These  vesicles,  as  well  as  the  ul- 
cerations  themselves,  are  very  small,  but  well  defined. 
One  will  see  a  little  pit  with  yellowish  or  grayish 
sides.  There  may  be  but  a  single  one  or  the  cornea 
may  be  dotted  all  over  with  them.  More  or  less  in- 
jection of  the  small  ciliary  vessels  about  the  corneal 
border  is  to  be  seen,  and  in  some  instances  not  only 
are  the  surrounding  conjunctival  vessels  similarly  en- 
larged, but  they  may  extend  into  the  corneal  tissue,  so 
as  to  produce  a  true  pannus  very  like  what  one  oc- 
casionally sees  with  granular  lids.  As  a  rule  the  dis- 
ease improves  rapidly  under  treatment,  and  in  a  few 
weeks  the  small  patient  is  well.  This  is  not  always 
the  case,  however.  The  ulcerations  may  become  so 
extensive  as  to  be  serious,  and  may  even  go  on,  in  un- 
healthy children  not  properly  fed,  to  perforation  of 
the  cornea  and  to  destruction  of  the  eye.  In  nearly 
all  instances  cicatricial  opacities  remain.  If  the  ulcers 


—  6i  — 

have  not  been  deep,  and  efficient  treatment  has  been 
resorted  to,  these  scars  finally  disappear. 

This,  by  the  way,  is  true  of  all  superficial  corneal 
scars  as  we  find  them  in  children.  One  should  always 
feel  encouraged  to  persevere  (by  massage  with  mild 
yellower  red  mercurial  ointment,  ^  to  2  percent., 
etc.)  in  attempts  to  remove  these  damaging  interfer- 
ences with  vision. 

Turning  to  the  small  patient  who  forms  the  text 
for  this  ophthalmic  sermon,  we  find,  as  anticipated, 
that  the  cocaine  has  greatly  relieved  the  reflex  spasm 
of  the  lids,  so  that  we  are  able,  by  the  exercise  of  a 
little  tact,  to  get  a  good  view  of  both  corneae.  The 
small,  discrete,  grayish  ulcers — one  in  the  left,  two  in 
the  right  eye,  all  of  them  near  the  centre  of  the  cor- 
nea— are  plainly  seen  against  the  dark-brown  back- 
ground of  the  iris,  and  we  notice  that  the  circumcorneal 
injection  is  considerable.  In  a  previous  lesson  on 
"Iritis"  I  remarked  that  in  young  children  well-marked 
"photophobia"  means,  in  nine  cases  out  of  ten,  phlyc- 
tenular  keratitis,  but  one  should  never  be  contented 
with  a  knowledge  of  this  fact  alone.  To  see  the  phlyc- 
tenules,  to  observe  their  size  and  situation,  t6  count 
their  number,  and  to  decide  what  stage  of  develop- 
ment they  have  reached,  is  the  only  common-sense 
method  of  diagnosis.  We  must  observe,  as  we  do  in 
this  case,  whether  there  is  any  concomitant  disease  of 
the  other  ocular  structures;  that  there  is  no  iritis  and 
no  conjunctivitis.  Practically  speaking,  iritic  compli- 


—    62    — 

cations  are  rare,  while  phlyctenules  of  the  conjunctiva 
(especially  at  the  sclero-corneal  margin)  are  not  un- 
common and  should  always  be  looked  for.  There  are 
none  in  this  case. 

Now,  how  should  we  treat  this  little  patient,  and, 
incidentally,  what  is  the  treatment  of  phlyctenular 
keratitis?  The  child  before  us  has  that  form  of  the 
disease  known  as  solitary  phlycte nulcc.  I  do  not  know 
that  therapeutically  this  classification  is  of  value,  but 
it  has  a  clinical  significance,  for  it  serves  to  distin- 
guish those  cases  where  there  is  no  tendency 
towards  the  formation  of  more  than*bne  or  two  ulcers 
from  others  in  which  the  cornea  becomes  very  shortly 
the  seat  of  numerous  phlyctenules. 

The  first  thing  to  do,  in  every  instance,  is  to  look 
well  after  the  general  health.  The  daily  life  of  the 
small  patient  should  be  carefully  inquired  into,  and 
one  should  insist  upon  its  being  compelled  to  con- 
form as  closely  as  possible  to  the  ordinary  laws  of 
hygiene.  These  are  not  mere  empty  words,  such  as 
is  the  fashion  nowadays  to  employ  in  embellishing 
papers  on  therapeutics  An  over-,  under-,  or  badly-fed 
and  hoiked  child  will  have  a  flourishing  crop  of  pus- 
tulous ulcers  for  an  indefinite  number  of  weeks  or 
months,  in  spite  of  other  treatment,  while  these  will 
go  on  to  reparation  at  once  if  a  programme  of  living 
which  includes  common-sense  diet,  fresh  air,  and  reg- 
ular bathing,  be  adhered  to  in  addition  to  the  other 
remedies.  Further,  the  state  of  the  bowels  (constipa- 


_  63  — 

tion  or  diarrhoea  is  often  present),  blood  (anaemia, 
chlorosis,  scrofula,  etc.,  are  to  be  looked  for),  and  skin 
(eczematous  eruptions  are  frequent)  should  not  be 
neglected. 

Notwithstanding  the  apparent  photophobia,  do 
not  allow  the  child  to  remain  curled  up  in  a  dark  cor- 
ner all  day,  but  see  that  he  or  she  is  taken  out  often 
for  fresh  air  and  sunshine. 

Whether  the  disease  be  a  true  eczema  or  not,  I 
believe  in  giving  Fowler's  Solution  (TIJJ  j,  to  be  in- 
creased gradually)  three  times  a  day  after  food,  and  I 
think  benefit  will  be  derived  from  it,  more  particularly 
in  those  instances  where  general  eczema  is  present. 
For  any  accompanying  facial  eczema,  also,  I  have 
always  seen  the  best  results  from  applying  the  same 
ointment  to  the  face  that  I  would  apply  to  the  eye, 
viz.,  a  YZ  to  i  per  cent,  mixture  in  "  cold  cream  "  of 
the  yellow  oxide  of  mercury.  This  mixture  I  give  to 
the  patient  for  use  at  home  (a  piece  the  size  of  a  pin- 
head  to  be  put  into  the  eye  two  or  three  times  a  day), 
and  if  necessary  use  a  stronger  mixture  (2  to  3  per 
cent.)  myself  once  or  twice  a  week.  In  the  use  of 
both  these  ointments  I  am  guided  by  the  amount  of 
irritation  which  they  cause.  If  the  eye  becomes 
"  red  "  under  the  use  of  one  or  the  other,  I  stop  them 
for  a  time  or  change  the  treatment.  Sometimes  I 
have  found  calomel  of  use,,  instead  of  the  weaker 
ointment.  This  should  be  dusted  into  the  eye  with  a 
camel's-hair  brush  once  or  twice  daily.  The  only  ob- 


-  64  - 

jection  to  it  is  that  it  requires  a  skilled  hand  to  do  the 
dusting  effectually  and  properly.  In  all  instances  I 
have  been  in  the  habit  of  using  atropine  to  dilate  the 
pupil;  once  a  day  is,  as  a  rule,  often  enough  to  apply 
it — a  few  drops  of  a  one  per  cent,  solution.  If  eser- 
ine  be  preferred  (as  it  may  be  when  the  phlyctenulae 
are  numerous,  when  they  are  peripheral,  or  when  they 
threaten  to  perforate  the  cornea),  it  is  well  to  combine 
it  with  cocaine.  A  good  formula  is: 

IJ     Eserinae  sulph gr.  i . 

Cocainae  mur gr.  vi . 

Liq.  hydrarg.  bichlor.,  i  :  5000 fl.  £  j  • 

M.  et  sig. — Two  drops  to  be  put  into  the  eye  three  or 
four  times  a  day. 

I  would  still  keep  the  pupil  dilated  with  atropine, 
as  it  probably  does  not  interfere  with  the  curative 
effects  of  the  eserine. 

The  relief  of  the  "  photophobia,"  or  spasm  of 
the  lids,  is  important.  Spraying  the  eyes  with  ice- 
cold  water,  or  dropping  it  on  the  closed  lids,  as 
Oppenheimer  suggests,  in  conjunction  with  the  occa- 
sional instillation  of  cocaine  (2  per  cent,  solution),  will 
be  found  to  give  great  relief  and  be  very  grateful  to 
the  patient. 

The  child  should  wear  a  shade  in  the  house,  and 
a  light  porous  bandage  over  the  affected  eyes  when 
he  is  taken  out.  Later -on,  smoked  or  blue  glasses 
(coquilles)  (30)  will  answer  both  purposes. 

To  keep  the  eyes  perfectly  clean  with  some  anti- 


-  65  - 

septic  solution,  which  shall  also  act  upon  the  ulcera- 
tions,  is  good  surgery.  I  have  never  been  able  to  see 
the  necessity,  however,  for  washing  out  the  eyes  every 
hour,  as  some  authorities  advise.  It  is  entirely  too 
frequent.  Aside  from  the  difficulty  met  with  in  get- 
ting the  eyes  open,  it  seems  to  me  that  the  worry  oc- 
casioned the  child  in  attempting  to  accomplish  it  does 
more  harm  than  good.  On  the  other  hand,  a  mild 
solution  (3  per  cent.)  of  boric  acid,  or  of  chlorine 
water,  applied  with  a  dropper  four  times  a  day  and 
once  during  the  night,  is  decidedly  helpful.  Some 
firmness  and  a  little  coaxing,  joined  to  the  effects  of 
a  few  drops  of  the  cocaine  solution,  will  generally 
enable  the  nurse  to  apply  the  antiseptic  bath. 

Finally,  do  not  forget  that  the  patient  is  nearly 
always  "  below  par,"  has  a  poor  appetite,  a  coated 
tongue,  and  an  indifferent  digestion.  My  favorite 
prescription  under  these  circumstances  is:  Tr.  nucis 
vom.,  TTJJ  ij,  in  3  ij  of  "  beef,  iron  and  wine."  Children 
take  this  mixture  well.  If  necessary,  peptonized  milk 
should  be  given  with  the  other  food.  All  such  indi- 
gestible trash  as  ice-cream,  greasy  cakes,  candies,  et 
hoc  genus  omne,  should  be  proscribed. 

FOREIGN  BODIES  IN  THE  CORNEA.  —  The  "some- 
thing "  which  gets  into  a  patient's  eye  is  usually 
washed  towards  the  inner  canthus,  out  of  harm's 
way,  by  the  stream  of  tears  excited  by  its  presence. 
But  if  it  has  sharp  edges  or  corners  it  may  stick  into 
the  cornea  —  if,  indeed,  the  force  that  sends  it  into  the 


5 


—  66  — 

eye  has  not  already  driven  it  into  that  structure. 
Removal  of  these  is  usually  done  under  cocaine,  by 
means  of  a  "spud  "  (Fig.  9). 


S-TJEMANN4CO 


FIG.  9. 

It  is  wise  to  try  and  pry  the  object  out  of  its  bed 
rather  than  to  sciape  it  away.  Iron  or  steel  chips  are 
readily  attracted  by  the  electro-magnet,  and  when 
they  are  deeply  situated  or  project  into  the  anterior 
chamber,  this  is  the  safest  method  of  removal.  To 
prevent  infection  (31)  of  the  wound  produced  by  the 
foreign  body,  a  lotion  of  boracic  acid  with  corrosive 
sublimate  (27),  should  be  used  several  times  daily  for 
a  week. 

INTERSTITIAL  KERATITIS  is  a  very  chronic  in- 
flammation of  the  cornea,  the  result  in  most  instances 
of  inherited  syphilis  The  child— for  it  is  essentially 
a  disease  of  childhood — nearly  always  presents  some 
of  the  well-known  signs  of  congenital  syphilis: — the 
notched  (Hutchinson)  incisor  teeth,  the  sallow  skin, 
the  anaemic  lips,  the  broad  depressed  nose,  the  scars 
at  the  angle  of  the  mouth,  and  the  absent  naso-labial 
depressions.  The  mother,  if  questioned,  will  be 
found  to  have  had  several  miscarriages  or  dead-born 
children.  Deafness,  from  internal  ear  disease,  is  a 
not  infrequent  accompaniment  of  this  parenchymatous 
keratitis.  It  begins  very  insidiously  as  a  slight  gray- 


—  67  — 

-ish  opacity  near  the  upper  margin  of  the  cornea.  At 
the  same  time  the  vessels  in  that  region  become 
injected  and  reach  out  to  join  the  infiltration.  The 
vascularhy  increases  with  the  grayish  opacity  until  a 
yellowish  area  is  formed,  to  which  the  name  "  salmon 
patch  "  has  been  given.  Little  by  little  the  opaque 
patch  increases  in  size,  other  spots  form  and  coalesce, 
until  finally  the  whole  cornea  presents  an  irregular 
grayish-white  aspect,  intersected  by  numerous  blood- 
vessels. The  epithelium  of  the  affected  parts  loses 
its  smooth  appearance  and  looks  like  ground  glass. 
This  stage  of  the  disease  may  extend  over  several 
weeks  or  months.  When  the  cornea  has  reached  a 
condition  of  extreme  opacity  it  remains  unchanged 
for  a  longer  or  shorter  period,  and  then  begins  to 
clear  up.  The  process  of  absorption  and  repair  now 
goes  slowly,  on,  translucent  areas  show  themselves 
here  and  there,  and  finally  portions  of  the  iris  and 
pupil  can  be  seen,  and  after  many  weary  weeks  of 
waiting  the  cornea  may  become  quite  or  almost  as 
transparent  as  before.  This  is  the  usual  course  of 
the  disease,  and  the  patient's  friends  can  be  encour- 
aged to  persevere  with  remedies,  however  unprom- 
ising the  outlook  may  seem.  There  is  always  more 
or  less  pain,  lacrymation  and  photophobia,  and  some- 
times spasm  of  the  lids.  Iritis,  as  well  as  more  deeply 
seated  inflammation  of  the  eye,  may  be  present.  If 
the  eyeball  is  tender  and  the  tension  (9)  is  lessened, 
these  complications  may  be  suspected. 


—  68  — 

Abscess  and  ulceration  of  the  cornea  are  seldom- 
or  never  present,  although  some  pus  cells  probably 
collect  about  the  inflammatory  foci.  Usually  both 
eyes  are  attacked — one  after  the  other.  It  often  hap- 
pens that  as  one  eye  is  getting  well  the  other  becomes 
affected — a  fact  to  be  borne  in  mind  in  delivering  an 
opinion  to  the  patient  or  his  parents.  Proper  treat- 
ment may  shorten  the  duration  of  this  disease,  but  it 
often  lasts  six  or  eight  months  under  the  most  atten- 
tive care.  Prognosis  is  generally  favorable,  but  in 
view  of  the  possibility  of  incomplete  clearing  up  of 
the  cornea,  as  well  as  the  chances  of  iritis,  chloroiditis 
and  other  complications,  it  is  best  to  be  guarded  in 
this  particular. 

Treatment  should  first  of  all  be  directed  to  the- 
general  condition.  When  syphilis  or  struma  is  pres- 
ent constitutional  remedies  will  be  called  for.  In  the 
former  case  the  syrup  of  the  iodide  of  iron  is  invalu- 
able. To  this  short  and  intermittent  courses  of  mer- 
curous  (green)  iodide  may  be  added.  The  pupil 
should  be  kept  dilated  with  -weak  atropine  drops  (2 
grs.  to  the  f  ?•  j)  if  there  be  pain  or  tenderness  on 
pressure.  Tonics,  cod-liver  oil,  a  good  diet  and  fresh 
air  are  always  advisable  whatever  the  cause  of  the 
disease.  I  think  I  have  seen  good  results  from  mas- 
sage with  mild  mercurial  ointment  (26)  after  the 
acute  stage  has  passed.  Two  other  remedies  must 
not  be  forgotten:  ist,  fomentations  with  water  as  hot. 
as  can  be  borne  for  an  hour  three  times  daily;  and,. 


%.   »  —  6g  — 

•2nd,  the  application  of  a  small  blister  (2x2)  to  the 

'temple  about  once  a  fortnight.  These  constitute  a 
sort  of  routine  practice  in  which  I  have  much  faith 

-and  I  think  they  may  be  used  with  great  benefit  in  the 

.large  majority  of  cases. 

PUNCTATE  KERATITIS  may  be  known  by  the  for- 
mation of  numerous  dots  of  lymph  upon  Descemet's 
membrane — the  posterior  surface  of  the  cornea. 
These  fine  heads  arrange  themselves,  as  a  triangle  in 

"the  lower  corneal  semicircle  with  its  base  at  the  peri- 
phery and  its  apex  pointing  to  the  center  of  the  cor- 
nea. This  is  not  an  independent  disease  of  the  cornea 

"but  is  the  outcome  of  serous  iritis  (129)  and  sympathetic 

•  ophthalmia  (130). 

Treatment. — This  must  be  directed  mainly  to  the 

•  disease  with  which  the  punctate  spots  are  associated. 

Hypodermic  injections  of  pilocarpine  (24)  are  of 
value. 

ULCERS  OF   THE  CORNEA.      These   form   them- 

•  selves  into  several  clinical  groups,  but  as  commonly 
seen  they  may  be  divided  into  two  classes,   (i)    the 
simple,    non-spreading    ulcer;    (2)    the    serpiginous    or 

.spreading  variety.  Both  lesions  are  usually  the  result 
of  a  wound  of  the  cornea  (however  slight)  with  sub- 

•  sequent  infection.      For  example,  a  grain  of  coal,  a 
piece  of  metal,   or  other  foreign  body  becomes  em- 
bedded in,  or  some  other  agent  inflicts  a  wound  upon, 
the  cornea  of  a  patient  who    has   a   mucocele    (51), 
iblepharitis  (34),  or  it  may  be  some  form  of  conjunc- 


—  70  — 

tivitis.  The  micro-organisms  which  infest  the  secre- 
tions in  these  diseases  find  a  favorable  nidus  in  the- 
denuded  spot  caused  by  the  foreign  body  or  its  re- 
moval. They  multiply,  infiltrate  the  corneal  border 
of  the  wound  and  an  ulcer  results.  When  the  infec- 
tive process  is  not  a  very  active  one  the  ulcer  does 
not  increase  to  a  large  size  and  does  not  reach  the 
deeper  layers  of  the  cornea,  but  in  certain  other  cases- 
where  the  resistance  of  the  tissues  is  low  and  the 
supply  of  micrococci  large  and  vigorous  the  mdst 
serious  and  rapid  destruction  of  the  cornea  may  re- 
sult. 

SIMPLE  ULCER  is  usually  single,  central,  small,  of 
a  grayish-white  appearance  and  is  accompanied  by 
considerable  pain  and  lacrymation.  There  is  a  good 
deal  of  pericorneal  injection  and  some  photophobia. 
This  disease  may  be  distinct  from  phlyctenular  kera- 
titis  or  it  may  be  one  of  the  single  pustules  of  that 
disease  which  has  burst  and  become  an  ulcer  (57). 
The  treatment  is  practically  the  same  (63),  viz.:  atro- 
pine,  rest  to  the  eye,  and  frequent  use  of  a  hot  disin- 
fectant lotion  (31).  General  treatment  is  to  be  given 
if  needed  and  any  accompanying  conjunctival,  pal- 
pebral  or  lachrymal  disease  (49)  should  not  be  for- 
gotten. 

SPREADING  ULCER  (ulcus  serpens,  infecting  ulcer}- 
is  a  much  more  serious  disease  than  the  foregoing, 
although  its  beginning  may  be  the  same.  Its  chief 
characteristic  is  that  it  tends  to  spread  over  the  sur- 


face  of  the  cornea  and  to  eat  into  its  substance.  It 
presents  an  excavation  filled,  or  partially  filled,  with 
pus,  and  although  its  centre  is  more  opaque  than  the 
edges,  the  latter  are  surrounded  by  a  grayish  zone  of 
infiltration.  There  is  always  considerable  swelling 
of  the  conjunctiva  and  injection  of  both  the  deep 
and  the  superficial  vessels.  If  allowed  to  go  on 
the  ulcer  increases  in  size,  and  there  may  be  much 
(although  occasionally  there  is  very  little)  photo- 
phobia, pain,  and  lacrymation.  An  abscess  is  now 
very  likely  to  form  in  the  deep  layers  of  the  cornea 
(onyx),  and  a  stream  of  lymph,  mixed  with  escaped 
pus  cells,  slowly  trickles  down  from  it  into  the  an- 
terior chamber,  forming  a  yellowish-white  collection 
in  its  inferior  segment,  as  indicated  by  Fig.  10.  This 


FIG.    10. 

condition  is  termed  hypopyon.  Later  on  the  anterior 
chamber  may  gradually  fill  with  pus,  but  before  it  is 
completely  full  the  cornea  perforates,  the  purulent 
collection  escapes,  and  an  attempt  at  repair  follows, 
as  in  any  other  abscess.  But  the  inflammatory  action 
may  involve  the  iris  and  ciliary  body,  and  eventually 


—  72  - 

destroy  the  whole  eye.  When  a  perforation  occurs 
in  the  way  described  the  iris  almost  always  becomes 
entangled  in  the  wound,  and  if  the  ulcer  heals  there 
remains  a  thick,  opaque  scar  enclosing  a  larger  of 
smaller  portion  of  the  iris.  This  is  known  as  leucoma 
adherent.  There  is  then  no  useful  vision,  although 
an  artificial  pupil  (93)  may  improve  matters  consider- 
ably. 


FIG.   ii. 

Treatment. — As  soon  as  an  ulcer  is  found  to  be 
spreading  however  slowly,  the  infecting  organisms, 
whose  multiplications  are  the  cause  of  the  disease, 
should  be  destroyed.  There  are  many  methods  of 
accomplishing  this  end,  but  the  best,  quickest,  and 
least  painful  is  the  cautery  (31),  the  electro-cautery 
(Figs,  ii  and  12)  to  be  preferred.  *A  good  handle  and 
special  points  are  made  by  the  Mclntosh  Battery  Co. 


FIG.   12. 

The  eye  is  first  cocainized  and  the  ulcer  well 
cauterized,  no  harm  being  done  if  the  bottom  of  the 
ulcer  is  perforated  by  the  cautery  point.  Noyes  thinks 


that  scraping  the  ulcer  with  a  spud  (Fig.  9)  is  effectual, 
and  does  not  leave  such  a  thick  scar  as  the  cautery, 
but  other  authorities,  like  Swanzy  and  Scholer,  prefer 
the  latter.  After  cauterization,  impalpable  boracic 
acid  powder  should  be  blown  into  the  eye  every  three 
or  four  hours,  or  hot  boric  lotion  used  more  fre- 
quently. For  the  boric  acid,  mercuric  perchlonde 
solution  (1:5000)  may  be  substituted.  It  used  to  be 
the  practice  to  cut  through  the  whole  thickness  of  the 
ulcer  with  a  Beer's  knife — a  proceeding  called  Saemis- 
sA's  section — for  the  purpose  of  evacuating  the  hypo- 
pyon  and  to  lessen  the  pressure  in  the  anterior  cham- 
ber. If  after  a  few  days  following  the  cauterization 
the  pain  is  not  less,  or  if  the  ulcer  seems  about  to 
perforate,  or  if  the  collection  of  lymph  pus  in  the  an- 
terior chamber  does  not  begin  to  disappear  by  absorp- 
tion, a  paracentesis  should  be  done. 

This  is  a  simple  proceeding,  and  usually  carried 
•out  by  means  of  a  special  needle.  It  is  shovel-shaped, 
and  provided  with  a  stop  or  shoulder  to  prevent  its 
being  pushed  too  far  into  the  chamber  and  so  injuring 
the  lens.  The  point  of  the  needle  is  first  directed  at 
an  angle  of  45°  into  the  cornea,  and  then  pushed 
slowly  through.  Once  entered  as  far  as  the  shoulder, 
the  handle  should  be  depressed  until  the  point  touches 
the  posterior  corneal  surface,  and  then  slowly  with- 
drawn. The  aqueous  gradually  flows  off.  The  tap- 
ping maybe  repeated  as  often  as  is  necessary.  It 
maybe  made  through  the  centre  of  the  ulcer  or  at  the 


—    74  — 

bottom  of  the  chamber.     In  either  case,  more  or  less- 
hypopyon  matter,  if  present,  will  escape. 

HERPES  OF  THE  CORNEA  has  already  been  spoken 
°f  (37)-  The  clear  bead-like  vesicles  that  first  form 
are  rarely  seen.  They  soon  break,  and  their  place  is 
taken  by  irregular  spots  of  disturbed  epithelium, 
easily  detected  by  the  reflex  test  (7). 

SENILE  ULCER,  concentric  or  ring  ulcer,  is  most 
commonly  seen  in  persons  whose  nutrition  is  low — old 
people  especially.  It  travels  slowly,  is  confined  to- 
the  margin  of  the  cornea,  and  may  heal  at  one  end 
while  progressing  at  the  other. 

Treatment. — The  most  important  point  is  to  im- 
prove the  general  condition  and  to  increase  the  assim- 
ilating powers.  Paracentesis  (71)  through  the  ulcer 
is  indicated,  and  it  should  be  followed  up  by  the  local 
application  of  hot  sublimate  solution  (i :  10000).  Some- 
times, in  spite  of  all  treatment,  the  disease  goes  on 
until  the  eye  is  lost.  When  this  takes  place,  a  badly 
nourished  organism  is  to  blame.  The  disease  is  in 
reality  a  senile  gangrene  of  the  cornea. 

SEQUELS  OF  ULCERS  are,  so  far  as  the  cornea  is  con- 
cerned, facet,  astigmatism  (R.  42),  opacities,  and  staphy- 
loma  anterius.  The  two  former  have  to  do  with  irregu- 
larities of  the  corneal  surface  produced  by  the  disease. 
Instead  of  a  regularly  round  and  smooth  surface, 
some  ulcers  in  healing  leave  a  transparent  but  faceted 
spot  which  greatly  interferes  with  good  sight,  and 
may,  if  central,  damage  vision  by  producing  irregular 


<>^~ 


—  75  — 

astigmatism  [C.  21,  R.  42].  The  healing  of  a  peri- 
pheral ulcer  may  also  change  the  shape  of  the  cornea 
and  bring  about  astigmatism. 

OPACITIES  OF  THE  CORNEA  are  very  common, 
and  may  result  from  any  of  the  diseases  which  inter- 
fere with  its  nutrition.  Granular  lids  (M.  45),  oph- 
thalmia neonatorum  (M.  81),  gonorrhceal  ophthalmia 
[M.  86],  the  various  kinds  of  keratitis  (56),  ulcers, 
etc.,  are  fruitful  sources  of  them.  It  goes  without 
saying  that  central  opacities  interfere  more  with  sight 
than  peripheral  blemishes.  Even  when  they  are  very 
faint — so  faint  as  to  be  scarcely  visible  to  the  unas- 
sisted eye  (9) — vision  may  be  lowered  by  their  pres- 
sure from  f-§  to  f-$,  or  one-half.  When  of  this  de^ 
scription,  faint  and  hazy,  they  are  termed  nebula.  A 
more  opalescent,  less  translucent  scar  is  called  a 
macula,  while  a  dense,  white,  and  quite  opaque  cica- 
trix  goes  by  the  name  of  leucoma. 

In  children,  especially  when  the  opacity  is  recent, 
it  is  wonderful  how  much  can  be  done  to  re- 
move opacities  of  cornea — even  maculae.  The  older 
the  patient  and  the  cicatrix  the  less  the  probability 
that  the  scar  will  be  removed. 

Treatment.  That  the  absorption  of  scar  tissue 
may  take  place  it  is  advisable  that  the  blood  supply 
to  the  cornea  should  be  larger  than  normal.  In  re- 
cent cases  of  ulcer  it  is  well  to  prevent  the  atrophy 
and  disappearance  of  the  blood  vessels  of  repair 
which  run  in  the  corneal  tissue  to  the  lesion  from  the 


_  76  - 

conjunctival  margin.  Both  these  objects  are  best 
attained  by  the  local  use  of  remedies  calculated  to 
slightly  irritate  the  cornea  and  conjunctiva.  Of  these 
by  all  means  the  most  efficient  is  massage  with  the 
oxide  of  mercury,  or  citrine  ointment  (27).  A  little 
should  be  placed  in  the  conjunctival  sac  and  thor- 
oughly, though  gently,  rubbed  once  or  twice  daily  and 
for  five  minutes  at  a  time  upon  the  corneal  surface 
through  the  closed  eyelids.  This  system  of  massage 
is  very  useful  in  many  cases  of  chronic  diseases  of 
the  conjunctiva  and  cornea.  Another  plan  (Berry)  is 
to  put  into  the  eye  once  a  day  a  drop  or  two  of  equal 
parts  of  turpentine  and  olive  oil.  If  these  measures  fail 
to  bring  vision  up  to  -/-fo  an  optical  iridectomy  (93) 
is  indicated.  The  iridectomy  itself  often  assists  the 
absorption  of  the  opacity  in  some  mysterious  way. 
It  should  be  made,  if  possible,  in  the  lower-inner 
quadrant,  since  rays  of  light  from  both  near  and  dis- 
tant objects  reach  the  macula  more  perfectly 
throughly  an  artificial  pupil  made  here  than  in  any 
other  part  of  the  iris. 

However,  the  greatest  amount  of  opacity  may  be 
in  this  situation  and  then  the  lower-outer  quadrant 
stands  next  in  order  of  preference.  The  two  upper 
quadrants  are  partly  covered  by  the  upper  lid  and 
are  least  desirable. 

STAPHYLOMA  ANTERIUS.  The  scar  tissue  result- 
ing from  a  deep  ulcer  is  not  as  resistant  of  intra-ocular 
pressure  as  the  normal  cornea.  It  sometimes  hap- 


—  77  — 

pens  that  the  weak  cicatrix  gives  way  under  this 
pressure,  stretches  and  produces  an  unsightly  bulging 
forward  of  the  cornea.  This  bulging  may  become  so 
great  that  the  lids  cannot  be  closed  over  it. 

Treatment.  An  iredictomy  should  first  of  all  be 
performed,  in  the  hope,  as  sometimes  happens,  that 
it  will  arrest  the  progress  of  the  deformity.  If  it 
does  not  enucleation  (132)  or  evisceration  (the  removal 
of  the  entire  contents  of  the  globe)  must  be  done. 

TATTOOING  THE  CORNEA  is  an  efficient  method 
of  covering  over  unsightly  white  leucomata  or  maculae. 
The  best  India  ink  (in  the  form  of  paste)  should  be 
used,  the  cornea rmust  be  well  cocainized  and  the 
coloring  matter  is  driven  obliquely  into  the  scar  by 
means  of  two  or  three  fine  needles  mounted  in  a 
handle  or  firmly  set  in  a  piece  of  cork  (Fig.  13).  Two 
sittings  are  usually  enough  to  complete  the  work, 
which  will  have  to  be  repeated  every  six  months  or 
every  year. 


FIG.  13. 

SCLERITIS  AND  EPiscLERiTis.  In  these  diseases 
(and  it  is  difficult  to  separate  the  one  from  the  other) 
there  is  scleral  injection,  pain  (severe  in  some  cases, 
almost  absent  in  others)  and  swelling  of  a  purplish 
color  at  the  point  affected — usually  3-4  mm.  from 
the  sclero-corneal  junction. 


It  is  not  a  common  affection  and  is  likely  to  be 
mistaken  for  conjunctivitis  or  iritis.  A  little  care 
will  detect  the  circumscribed  reddish  swelling  or 
swellings  which  characterize  the  disease. 

After  recovery  dark  pigmented  patches  often  re- 
main to  indicate  the  site  of  the  acute  lesion.  It  is 
more  frequent  in  women  than  in  men,  is  often  obsti- 
nate and  chronic  and  is  nearly  always  caused  by  the 
poison  of  rheumatism. 

Treatment.  Hot  fomentations,  atropine,  goggles 
and,  when  there  is  much  pain  and  pericorneal  injec- 
tion, leeches  (21).  The  rheumatic  taint  should  be 
neutralized  by  potassic  iodide,  sodic  salicylate  and 
other  appropriate  remedies. 

When  the  acute  symptoms  have  been  relieved, 
great  benefit  may  be  derived  from  massage. 


LESSON  VI. 

DISEASES  OF  THE  IRIS  AND  ANOMALIES  OF  THE 
PUPIL. 

•Coloboma  of  the  Iris — Differences  in  Color — Albinism — Nys- 
tagmus— Iridodialysis — Various  Kinds  of  Iritis — Iridec- 
tomy — Variations  in  the  Size  of  the  Pupil — Myosis  and 
Mydriasis — Various  Conditions  which  Produce  Anoma- 
lies of  the  Pupil — Hippus. 

It  sometimes,  though  rarely,  happens  that  a  sec- 
tion of  the  iris  is  congenitally  absent.  This  condi- 
tion, which  resembles  that  produced  by  iridectomy 
(93)  goes  by  the  name  of  COLOBOMA.  It  occurs  in 
the  lower-inner  quadrant  of  the  iris  and  is  usually  ac- 
companied by  other  deficiences  within  the  eye  and 
about  the  head.  Vision  is  not  much  affected  by  it. 

CONGENITAL  DIFFERENCES  OF  COLOR  (heteroph- 
thalmos)  are  occasionally  to  be  seen.  One  iris  may  be 
blue,  while  its  fellow  is  brown,  or  a  portion  of  the 
same  iris  may  be  one  shade  or  color  and  the  remain- 
der of  quite  a  different  hue. 

ALBINOS,  condition  Albinism,  have  little  or  no 
pigment  in  the  iris  and  choroid.  These  persons  have 
white  hair  and  pink  irides.  They  ''screw  up"  their 
-eyes  to  exclude  the  light  because  the  choroidal  pig- 
ment, which  prevents  excessive  retinal  irritation  from 
unabsorbed  light  waves,  is  absent.  They  strive  to  ex- 
clude a  portion  of  the  light  by  reducing  the  aperture 
to  a  mere  slit. 


—  8o  — 

NYSTAGMUS  is  a  common  accompaniment  of  al- 
binism. It  may  be  described  as  a  spasmodic  jerking 
of  the  eye-balls  of  nervous  origin  and  is  often  wit- 
nessed in  affections  of  the  retina  and  optic  nerve. 

Treatment.  Any  defect  of  refraction  should  be 
remedied,  and  tinted  spectacles,  having  a  narrow  slit 
in  them  (stenopaic  glasses) ,  may  be  ordered.  The  pa- 
tient should  of  course  be  first  tested  with  a  stenopaic 
obturator  from  the  trial  case  (R.  8)  to  discover  in 
which  meridian  he  sees  best. 

IRIDODIALYSIS,  or  the  separation  of  the  iris  from 
the  ciliary  body,  is  always  the  result  of  blows  upon 
the  eye.  More  or  less  bleeding  into  the  anterior 
chamber  (hyphcema)  accompanies  this  lesion.  The 
use  of  atropine  is  indicated  in  the  hope  that  the  edges- 
of  the  wound  may  unite. 

IRITIS.  Inflammation  of  the  iris.  The  following 
account*  will  serve  to  indicate  the  salient  features  of 
the  several  varieties  of  iritis — one  of  the  most  import- 
ant ocular  affections  the  practitioner  has  to  deal  with. 

The  history  which  G.  W.,  aet.  22,  gives  of  himself,, 
as  he  comes  in  with  a  bandage  over  his  left  eye,  is  the 
following:  Six  years  ago  he  had  an  attack  of 
"  inflammation  "  in  both  eyes,  and  was  treated  for  it 
with  "eye  water."  Since  then-  he  has  had  three  simi- 
lar attacks,  the  last  one  (for  which  he  now  presents 

*Abstracted  from  a  clinical  lecture  by  the  author  on 
"Ordinary  Forms  of  Iritis,"  from  the  North  American  Prac- 
titioner, July,  1890. 


—  8i   — 

himself  for  treatment)  affecting  him  as  did  the  others. 
His  eyesight  each  time  after  recovery  from  two  of 
the  attacks  has  been  noticeably  weaker  than  before. 
On  inquiry  the  patient  denies  that  he  has  or  ever 
had  any  venereal  disease  (and  there  are  no  signs  of  it 
about  his  person),  but  he  has  a  distinct  history  of 
rheumatism.  The  eye  affection  first  followed  upon 
an  attack  of  acute  rheumatic  arthritis,  with  which  he 
was  laid  up  for  two  months,  and  he  has  since  then 
had  several  attacks  of  the  same  disease.  Regarding 
the  present  attack,  he  says  it  resembles  the  others, 
only  that  the  general  rheumatic  symptoms  are  very 
slight.  It  has  already  lasted  three  days.  He  com- 
plains of  considerable  pain  in  the  supra-orbital  region, 
and  he  says  the  whole  side  of  his  head  aches.  His 
left  eye  is  decidedly  "  red; "  it  "  waters  "  a  good  deal; 
there  is  considerable  photophobia,  and  the  pupil  is 
smaller  than  on  the  right  side.  His  eyelids  do  not 
stick  together,  and  there  is  no  discharge  of  pus  or 
muco-pus  from  the  eye.  He  also  complains  of  pain  on 
touching  the  eyeball.  He  makes  no  complaint  about 
the  right  eye.  We  shall  put  a  few  drops  of  a  4-grain 
solution  of  sulphate  of  atropia  into  both  eyes,  have  him 
wait  half  an  hour  or  so,  and  notice  the  result. 

The  disease  from'  which  the  patient  suffers  is 
iritis,  probably  of  rheumatic  origin,  and  the  impor- 
tance of  a  correct  and  early  diagnosis  in  all  of  this 
class  of  cases  is  so  great  that  it  would  be  well  to  ask 
ourselves:  (i)  What  are  the  most  reliable  and  most 

6  zz 


—    82    — 

useful  signs  and  symptoms  of  inflammation  of  the  iris? 

(2)  What  diseases  is  one  most  likely  to  mistake  it  for, 
and  how  can  it  be  distinguished  from  these  affections  ? 

(3)  What  will  probably  occur  if  an  early  diagnosis  is 
not   made,  and  efficient  treatment  resorted  to  ?     (4) 
What  treatment  accomplishes  most  good  in  the  several 
varieties  of  this  inflammation  ? 

As  a  necessary  preliminary  to  these  questions, 
one  might  further  inquire,  What  is  the  essential 
nature  of  iritis — its  pathology?  Simply  that  of 
inflammation  in  a  highly  vascular  structure.  The  iris 
is  a  mixture— speaking  roughly— of  a  small  percent- 
age each  of  unstriped  radiate  and  circular  muscular 
fibers,  nerve  fibers  and  endings,  ganglia,  brown  pig- 
ment, and  lymphatics,  interspersed  with  a  larger  pro- 
portion of  blood-vessels  and  lymphatics— a  fine  field 
for  inflammatory  processes  to  run  riot  in.  Its  ante- 
rior surface  is  uneven — dotted  over,  here  and  there, 
with  small  hills  and  valleys,  all  of  which  are  clothed 
with  the  color-giving  pigment.  Remember,  too — for 
it  has  its  place  in  diagnosis — that  everybody's  irides, 
it  matters  not  what  color  they  may  appear  to  the  ob- 
server— blue,  brown,  gray  or  black — contain  the  same 
kind  and  almost  the  same  amount  of  this  brownish 
•coloring  matter.  It  is  its  variety  of  arrangement  on 
the  iris  surface  that  gives  rise  to  the  different  color 
impression. 

It  is  possible,  I  think,  to  trace  the  "  cardinal 
signs  "  of  inflammation  in  such  a  case  as  we  have  ex- 


-  83  - 

amined.  Inflammatory  redness  is  not  developed  in 
the  iritic  tissue  itself,  but  is  found  at  the  corneal 
margin.  Enlarged  vessels,  which  are  the  cause  of 
the  sign  of  redness  in  inflammation  of  tissues,  are, 
without  doubt,  present  in  the  substance  of  the  iris, 
but,  for  obvious  reasons,  they  are  not  manifest. 

What  one  does  see  at  the  commencement  of  an 
-attack — and  it  is  well  seen  in  our  patient — is  a  faint 
zone  of  redness,  about  5  mm.  in  width,  encircling  the 
cornea.  If  we  look  at  the  eye  with  a  magnifying 
glass,  this  pinkish  circlet  is  seen  to  be  due  to  a  num- 
ber of  small  and  almost  straight  vesssls,  which  do  not 
lie  in  the  conjunctiva,  but  are  under  it.  This  is 
proved  (6)  by  gently  pushing  the  overlying  mucous 
membrane  to  one  side;  these  fine  vessels  do  not  move 
with  it.  Not  much  reliance,  however,  can  be  placed 
upon  redness  as  a  diagnostic  sign  when  the  iritis  is 
•severe,  because  all  the  vessels  of  the  conjunctiva,  iris 
and  sclera  become  involved  in  the  inflammatory  pro- 
cess. If  one  studies  the  vascular  supply  of  the  eye- 
ball, it  will  be  seen  that  the  iritic  vessels  anastomose 
with  those  of  the  conjunctiva  on  the  outside  of  the 
globe,  and  form  part  of  the  uveal  plexus  within. 
Change  in  color  is  somewhat  allied  to  the  sign  of  red- 
ness, and  in  the  case  under  observation  is  so  marked 
that  even  the  most  casual  observer  would  be  sure  to 
remark  it. 

The  patient  has  a  mud-colored  left  eye  and  a 
blue  right  one.  When  inflamed,  the  iris  loses  its  deli- 


-  84  — 

cate  velvety  gloss  and  tracery;  blue  eyes  look  clay- 
colored,  brown  eyes  assume  a  greenish  hue,  and  so 
on.  When  both  eyes  are  affected  this  is  not  so 
marked,  as  there  is  no  contrast  between  the  two  sides. 

Swelling  is  a  sign  not  easily  made  out  in  iritis, 
but  its  presence  brings  about  a  very  noticeable  fea- 
ture of  the  disease — a  contracted  pupil.  The  infiltra- 
tion of  the  loose  tissues  of  the  iris  by  inflammatory 
products  causes  the  pupillary  margins  to  approach,, 
and  the  pupil  becomes  smaller. 

Pain  is  almost  always  present.  It  varies  greatly 
in  intensity,  aud  is  one  of  the  characteristic  elements 
of  the  disease.  It  usually  increases  in  violence 
towards  evening,  eases  off  in  the  night  time,  and  may 
get  worse  again  in  the  early  morning.  It  affects 
preferably  the  temple,  vertex,  and  the  globe  itself — 
in  reverse  order.  / 

The  supra-orbital  twig  of  the  trigeminus  is  the 
efferent  nerve  chiefly  affected,  and  even  in  such  a 
mild  case  as  we  now  have  on  hand,  pressure  upon  it 
at  the  supra- orbital  notch  and  in  its  course  over  the 
forehead  reveals  several  sensitive  points. 

Likewise,  the  iris  suffers  when  inflamed,  from 
impairment  of  function;  the  pupil  does  not  dilate  when 
the  eyes  are  shaded  from  the  light,  nor  contract  to 
any  extent  when  suddenly  exposed  to  it. 

Iritis,  according  to  the  severity  of  the  attack, 
may  last  three  or  four  days,  or  it  may  continue  for 
months.  The  globe  is  nearly  always  tender  on  pres- 


_  85  - 

sure  while  the  disease  lasts.  This  sign  alone  is  often 
sufficient  to  distinguish  it  from  some  diseases  that  re- 
semble it.  Of  these,  by  far  the  most  important  are 
conjunctivitis,  neuralgige  of  head  and  face,  and  the 
various  forms  of  inflammation  of  the  cornea. 

One  of  the  commonest  and  most  unsatisfactory 
experiences  of  the  ophthalmologist  is  to  be  called 
upon  to  deal  with  an  old  iritis,  which  has  been  treated 
for  conjunctivitis.  Such  mistakes  ought  to  be  less 
frequently  made  than  they  are,  because,  beyond  the 
scleral  redness  caused  by  injection  of  the  vessels 
overlying  that  structure,  iritis  and  conjunctivitis  have 
nothing  in  common.  I  would  advise  the  non-specialist 
to  disregard  entirely  the  matter  of  vascular  injection 
in  the  diagnosis  of  external  eye  diseases.  It  is  en- 
tirely untrustworthy,  and,  as  compared  with  other 
signs  and  symptoms,  of  little  value.  For  the  sake  of 
-comparison  and  contrast,  let  us  picture  side  by  side 
the  salient  features  of  these  affections: 


CONJUNCTIVITIS. 

IRITIS. 

Muco-purulent    or    purulent, 
causing   morning    adhesion 

Discharge. 

Watery.    Does  not  cause  lids 
to  adhere. 

of  lids. 

Comparatively  little;  if  pres- 

Pain. 

Often  severe  and  neuralgic  in 

ent,     mostly    confined    to 

character.    Worse  at  night 

glob<\ 

and  in  the  early  morning. 

Not  affected. 

Vision. 

Affected  often  and  early. 

Not  much;  often  none. 

Photo- 

Nearly alwajs  present. 

phobia. 

Dilates  when  eyes  are  shaded. 

Pupil. 

Dilates    sluggishly  or  not  at 

all. 

Both  eyes. 

Disease 

May  affect  one  only,  or  one  at 

affects. 

a  time. 

.No  change  in  color  or  appear- 

Iris. 

Discoloration,    with    loss    of 

ance. 

velvety  gloss. 

—  86  — 

The  fact  does  not  appear  to  be  generally  known,, 
but  it  is  a  fact  nevertheless,  that  cases  of  iritis  are- 
sometimes  treated  as  hemicrania,  supra-orbital  neural- 
gia, facial  neuralgia,  malarial  headache,  etc.,  and 
neither  patient  nor  physician  is  meantime  aware  that 
a  serious  intra-ocular  inflammation  (of  which  the  pairt 
happens  to  be  the  most  urgent  symptom)  is  "blazing 
away"  unchecked.  The  "red  eyes"  are  in  such  cases 
attributed  to  "congestion  of  the  head,"  "hypereemia 
of  the  conjunctiva,"  or  to  some  such  cause.  Of 
course,  inspection  of  the  iris  would  correct  this  error 
of  diagnosis. 

There  is  only  one  way  to  separate  corneal  troubles 
from  iritis  when  (as  generally  happens  in  keratitis) 
intolerance  of  light  is  a  prominent  symptom,  and  that 
is  to  put  into  the  affected  eye  two  drops  of  a  lo-grain 
solution  of  cocaine  every  couple  of  minutes  for  a 
quarter  of  an  hour.  This  will  quiet  the  eye,  and  en- 
able one  to  obtain  a  good  look  at  the  cornea  and  iris. 
One  thing  is,  however,  worth  emphasizing  in  this  con- 
nection: If  the  patient  is  young — under  twelve  years- 
of  age — the  photophobia  is  almost  certain  to  be  due 
to  one  of  the  forms  of  inflamed  or  ulcerated  cornea^ 
and  not  to  iritis. 

Now  let  us  return  to  our  patient.  I  find  that  the 
atropine  has  dilated  one  of  the  pupils  quite  wide,  but 
the  other  resists  the  mydriatic.  I  have  made  a  sketch 
of  both  pupil  and  irides,  so  that  the  different  effects- 
of  the  drug  upon  them  may  be  seen. 


-  87   - 

Why  have  not  these  pupils  fully  dilated,  and 
what  do  their  irregular  margins  mean  ?  If  one  looks 
closely  at  the  right  pupil — illuminating  it  with  a  not 
too  strong  light — he  will  observe  that  a  portion  of  the 
iris  is  attached  behind  to  the  lens.  It  looks  as  if  a 
tack  had  been  driven  through  the  edge  of  the  iris  into 
the  lens,  and  so  prevented  it  from  being  drawn  back 
with  the  remainder  of  the  organ. 


FIG.  14. 

Such  a  'state  of  things  is  more  marked  in  tne  left 
eye.  Here,  indeed,  it  looks  as  if  the  receding  iris 
were  composed  of  two  layers,  an  anterior  and  a  pos- 
terior, capable  of  some  degree  of  motion  upon  one 
another,  and  that  the  posterior  were  "tacked  "  at  sev- 
eral points  around  its  margin  to  the  anterior  capsule 
of  the  lens.  When  the  whole  curtain  of  the  iris  was- 
drawn  back  by  the  atropine,  the  anterior  layer  seems 
to  have  yielded  in  its  entirety;  so  has  the  posterior, 
excerpt  at  those  points  where  it  was  not  adherent  to 
the  lens  surface.  And  this  is  about  what  has  hap- 
pened. The  swollen  iris,  during  some  previous  at- 
tack, has  (as  it  always  does  in  iritis)  come  in  contact 
with  the  lens,  and  inflammatory  adhesions  have  formed 


between  the  latter  and  the  posterior  surface  of  the 
iris.  These  adhesions — posterior  synechije,  they  are 
termed — at  first  soft  and  easily  broken  up,  have  be- 
come organized  and  fibrous — just  as  occurs  else- 
where— and  a  damaged  eye  is  the  consequence. 

As  a  rule,  the  more  frequent  the  attacks,  the 
greater  likelihood  of  connective  tissue  bands  forming 
in  the  way  described;  but,  on  the  other  hand,  a  single 
attack  of  iritis,  unless  properly  treated,  may  leave  an 
eye  in  the  condition  of  our  patient's  left.  Some  small, 
dark  spots  are  also  to  be  seen  in  the  background  of 
his  widely  dilated  right  pupil.  These  are  small  dots 
of  pigment,  which  have  been  torn  from  the  posterior 
iritic  layer  while  the  inflammatory  exudation  was 
recent.  It  often  means  that  atropine  has  been  used, 
and  that  it  is  the  resulting  mydriasis  which  has  pro- 
duced this  effect;  and  although  pigmentary  deposits 
on  the  surface  of  the  lens  sometimes  reduce  the 
acuteness  of  vision  when  they  are  close  to  the  cen- 
tre of  the  pupil,  they  are  less  objectionable  than  an 
iris  glued  to  the  lens  capsule.  As  a  result  of  these 
adhesions,  the  patient  may  suffer  not  only  from 
interference  with  vision  consequent  upon  a  partially 
obscured  pupillary  aperture,  but  the  adhesions  may, 
if  extensive  enough,  give  rise  to  more  serious  troubles. 
Indeed,  they  may  lead  to  actual  destruction  of  sight, 
from  certain  secondary  changes  in  the  eye  (cyclitis, 
glaucoma  (113),  etc.),  which  we  cannot  discuss  just  now. 
It  is  very  probable,  also,  that  the  continual  tugging  at 


-  89  - 

the  little  points  of  adhesion  (as  the  iris  attempts  to 
expand  and  contract)  may  dispose  the  damaged  iris 
to  recurrent  attacks  of  the  disease. 

The  iris  may  become  inflamed  as  the  result  of 
injury,  but  by  far  the  commonest  causes  of  this  con- 
dition are  syphilis,  gonorrhoea,  and  the  poison  of 
rheumatism.  It  is,  of  course,  very  important  to  get 
at  the  cause  of  the  iritis  in  a  particular  instance,  as 
upon  that  depends  in  a  great  measure  the  successful 
treatment  of  the  case.  In  syphilitic  iritis  the  inflam- 
mation is  usually  more  plastic  than  in  the  rheumatic  or 
traumatic  forms  of  the  disease,  and  it  may  show  itself 
as  a  secondary,  a  tertiary,  or  even  as  a  congenital 
manifestation.  It  probably  affects  both  eyes  more 
frequently  than  the  rheumatic  form.  The  latter  is, 
however,  the  most  obstinate,  and  the  most  liable  to 
recur  of  these  forms.  In  either  instance  proper  con- 
stitutional treatment  should  be  employed. 

The  pain,  if  not  severe,  is  often  relieved  by  hot 
applications.  Some  patients  like  dry  heat;  others 
prefer  wet  applications. 

Often  two  full  doses  of  antipyrin,  given  at  inter- 
vals of  two  hours  before  the  usual  exacerbation,  act 
magically,  and  secure  the  desired  sleep.  Cupping 
the  temples,  or  the  application  of  leeches,  is  good 
practice,  and  is  often  resorted  to. 

But  of  all  the  remedies  in  the  pharmacopoeia,  sul- 
phate of  atropia  (or,  if  it  causes  too  much  local  irrita- 
tion, (32)  some  salt  of  duboisia  in  the  same  dose)  is  by 


—  90  - 

all  odds  the  best.  It  matters  not  at  what  stage  of 
the  disease  one  sees  the  patient,  one  should  make  an 
effort  (by  instilling  into  the  affected  eye,  every  hour 
or  two,  a  few  drops  of  a  4-grain  solution)  to  dilate 
the  pupil.  When  that  is  accomplished,  every  four  or 
five  hours  will  be  sufficient.  My  practice  is  to  begin 
by  putting  in,  myself,  once  a  day,  until  as  complete  a 
dilatation  as  possible  is  accomplished,  as  much  as  can 
be  retained  in  the  conjunctival  sac  of  an  8-grain  to 
the  ounce  mixture  of  atropine  and  vaseline.  The 
effects  of  this  mixture  are  more  lasting  than  the  solu- 
tion, and  it  does  not,  I  think,  run  off  or  get  so  readily 
into  the  nasal  passages  and  produce  constitutional 
effects.  The  patient  meanwhile  uses  a  weaker  mix- 
ture or  the  solution  aforementioned — preferably  the 
solution — unless  you  can  feel  certain  that  some  com- 
petent person  will  apply  the  ointment  for  him. 

The  use  of  atropine  accomplishes  several  things. 
It  dilates  the  pupil,  and  so  prevents  the  dreaded  ad- 
hesions between  lens  and  iris.  It  relieves  the  neu- 
ralgic pains,  promotes  absorption  of  the  inflammatory 
exudations,  reduces  the  capillary  congestion,  and 
probably  cuts  short  the  disease.  Even  when  syne- 
chiae  have  formed,  it  may  tear  them  asunder,  if  the 
case  has  not  been  seen  too  late. 

So  potent  is  this  drug  that,  speaking  generally, 
one  may  affirm  that  when  the  pupil  has  been  dilated 
by  a  vigorous  use  of  atropine,  and  is  kept  dilated  by- 
smaller  doses  of  the  same  remedy,  the  disease  is  un- 


—  9I  — 

der  control,  and  recovery  soon  follows.  We  shall 
also  order  a  shade  for  this  patient,  which  he  must 
wear  over  his  eye  while  in  the  house.  It  is  best,  for 
many  reasons,  that  he  should  abstain  from  work,  and 
not  use  even  his,  as  yet,  unaffected  eye.  When  he 
comes  again  to  see  us,  it  must  be  on  a  fairly  mild  day, 
and  he  ought  to  wear  a  light  porous  bandage  (with- 
out a  pad)  over  the  left  eye. 

His  rheumatism  should  not  be  lost  sight  of.  I 
think  the  present  attack  of  iritis  should  be  considered 
as  a  sub-acute  manifestation  of  the  general  dyscrasia. 
We  must  treat  it  as  such  by  appropriate  remedies, 
well  known  to  the  profession. 

When  syphilis  has  been  the  cause  of  the  disease, 
the  character  and  dose  of  the  constitutional  remedies 
will  largely  depend  upon  the  relation  which  the  iritis 
bears  to  the  initial  lesion,  whether  the  former  be  a 
secondary,  a  tertiary,  or  a  congenital  manifestation. 
Overdosing  with  powerful  mercurial  remedies  is  al- 
ways to  be  deprecated.  Inunction  with  ungt.  hydrarg. 
once  daily — with  intermissions  of  three  days  after 
each  week's  use  of  the  ointment — combined  or  not 
with  potassic  iodide  internally,  will  be  found  to  act 
well.  In  gonorrhceal  iritis  the  eye  symptoms  experi- 
ence considerable  relief  when  the  urethral  discharge 
is  stopped. 

IRIDECTOMY. — When  the  iritis  is  of  the  recurrent 
form  a  broad  iridectomy  often  prevents  a  return  of 
the  disease  or  lengthens  the  interval  between  the  at- 


tacks.  The  operation  itself  is  performed  in  the  fol- 
lowing manner:  The  conjunctival  sac  having  first 
been  irrigated  (31)  with  an  antiseptic  solution,  and 
all  the  other  antiseptic  precautions  carried  out  (31),  a 


FIG.  15. 

4  per  cent,  solution  of  cocaine  is  dropped  into  the 
eye.  The  wire  speculum  (Fig.  15)  is  now  introduced, 
and  the  eye  being  steadied  by  fixation  forceps  (Fig. 


FIG.  16. 


16),  an  incision  is  made  at  the  sclero-corneal  junction 
with  a  narrow  Graefe  knife  (Fig.  17).    This  cut  should 


SHARP  &  SMITH. 


FIG.  17. 

be  made  in  the  same  way  as  for  cataract  (105),  but. 
should  not  be  as  wide  as  the  latter.  Or  a  keratome 
(Fig.  1 8)  specially  devised  for  this  purpose  may  be 


—  93  — 

employed.  If  the  latter  be  chosen,  it  is  first  entered 
at  right  angles  to  the  globe,  and  when  the  cornea  is 
pierced  the  handle  is  depressed  and  the  point  pushed 


g 

5^ 

FIG.  18. 

across  the  anterior  chamber  as  deeply  as  necessary. 
The  aqueous  begins  to  escape  as  soon  as  the  with- 
drawal commences,  so  that  the  sharp  point  of  the  in- 


FIG.  19. 

strument  should  now  be  made  to  hug  the  posterior 
surface  of  the  cornea,  else  the  lens  may  be  wounded. 
The  width  and  situation  of  the  corneal  opening  should 


FIG.  20. 


correspond  with  the  kind  and  size  of  the  iris  coloboma 
desired,  a  narrow  one  for  small,  optical  iridectomies, 


—  94  — 

and  a  wide  and  very  peripheral  one  for  recurrent 
iritis  (91)  or  glaucoma  (113).  (See  Fig.  19).  The 
fixation  forceps  is  now  given  to  the  assistant,  and  with 
iris  scissors  (Fig.  20)  in  the  right  hand,  iris  forceps 


FIG.  21. 

(Fig.  21)  are,  with  the  left,  entered  closed  and  carried 
along  the  posterior  corneal  surface  until  the  pupillary 
margin  is  reached.  Here  they  should  be  opened,  the 


FIG.  22. 

iris  grasped,  pulled  well  out  of  the  wound,  and  snipped 
off  with  one  cut  of  the  scissors  (see  Fig.  22)  close  to 
the  cornea.  This  part  of  the  operation  is  the  only 
one  attended  by  pain,  and  the  patient  should  be 
warned  of  it  and  assured  that  it  will  not  be  severe  and 
will  last  for  an  instant  only.  Care  should  now  be 
taken  that  the  edges  of  the  cut  iris  are  replaced  either 


—  95  — 

with  the  repositor  or,  what  is  still  safer,  by  gently 
stroking  the  cornea  over  with  the  rubber  spoon  (Fig. 
23). 


FIG.  23. 

THE  SIZE  OF  THE  PUPIL  varies  greatly  in  health 
and  disease.  For  example,  there  is  a  considerable 
degree  of  physiological  variation  due  to  the  different 
amounts  of  light  which  at  different  times  reach  the 
retina.  Also,  as  is  well  known,  the  pupil  contracts 
when  the  eye  accommodates  (C.  24)  for  near  vision, 
while  it  expands  on  again  looking  in  the  distance. 

MYOSIS,  or  tonic  contraction  of  the  pupil,  is  a 
very  important  symptom  of  disease  -of  the  spinal 
cord,*  and  as  such  is  commonly  called  spinal  myosis 
(125).  It  is  also  produced  by  drugs,  such  as  eserine, 
opium,  or  by  any  local  irritant  to  or  disease  of  the  iris. 

MYDRIASIS,  or  dilatation  of  the  pupil,  is  most 
commonly  due  to  the  action  of  atropine,  belladonna, 
or  some  other  mydriatic  (22),  but  may  result  from 
paralysis  of  the  contractor  fibres  of  the  iris,  due  to 
disease.  Thus  we  find  it  in  paresis  of  the  third  nerve 
(137),  in  glaucoma  (113),  in  optic  atrophy,  after  diph- 
theria (125),  and  in  several  other  nervous  disorders. 


*  Hypermetropic  individuals  (when  the  refractive  error 
is  considerable)  and  old  people  have  small  pupils. 


_  96  - 

In  diphtheria  this  paretic  symptom,  like  that  affecting 
the  pharyngeal  muscles,  tends  to  get  better  without 
treatment.  The  pupils  of  the  myope  and  of  hysteri- 
cal women  are  larger  than  normal. 

HIPPUS. — This  term  describes  an  alternate  con- 
traction and  expansion  of  the  pupil,  such  as  one  oc- 
casionally sees  in  cases  of  nystagmus  (80). 


LESSON  VII. 

CATARACT    AND    OTHER   AFFECTIONS    OF  THE 
CRYSTALLINE  LENS. 

Dislocation  of  the  Lens — Irido-donesis — Aphakia  or  Absence 
of  the  Lens — Cataract — Nuclear  and  Cortical  Cataract — 
Senile  Cataract — The  Operation  for  Removal — When  to 
Operate — After-Treatment — Complications — Soft  Catar- 
act— The  Zonular  or  Lamellar  Cataract  of  Children — 
Discission  or  Needling. 

DISLOCATION  OF  THE  LENS.  The  crystalline  is 
beautifully  swung  by  means  of  its  suspensory  ligament, 
or  zonula  of  Zinn,  from  the  ciliary  body  and  is  so 
arranged  as  to  withstand  the  influence  of  ordinary 
jars  or  injuries  to  the  ocular  region.  But  severe  blows, 
delivered  directly  upon  the  globe  may,  particularly  if 
the  ligament  be  weakened  by  disease  or  if  the  vitre- 
ous be  fluid  (117),  cause  rupture  of  some  of  the  sus- 
pensory fibres  and  the  lens  may  thus  become  dislo- 
cated. When  the  zonula  is  torn  to  a  slight  degree 
only,  the  dislocation  is  usually  correspondingly  slight; 
but  when  the  violence  is  considerable  and  directed 
towards  the  ciliary  region,  the  lens  may  be  torn  en- 
tirely away  from  the  ligament  and  driven  into  the  vitre- 
ous, into  the  anterior  chamber  or  even  through  the  burst 
sclerotic  underneath  the  conjunctiva.  In  every  case 
there  will  be  observed  more  or  less  trembling  of  the 
iris,  or  iridodonesis,  when  the  patient  is  told  to  look  in 

7  ZZ 


various  directions,  and  this  is  diagnostic  of  the  injury. 
Shortly  after  dislocation,  through  interference  with 
its  nutrition,  the  lens  grows  hazy  and  may  finally  be- 
come quite  opaque.  If  the  pupil  be  dilated  with 
homatropine,  or  better  still  with  cocaine  and  atropine, 
the  lens  may  be  made  out  by  means  of  reflected  light 
(20)  and  its  new  position  definitely  determined. 

The  power  of  accomodation  (C.  24)  is  lost  when 
the  crystalline  is  dislocated,  since  the  accident  neces- 
sarily interferes  directly  with  the  mechanism  of  the 
act.  For  the  reason  which  is  given  in  the  description 
of  aphakia  (98)  the  eye  also  becomes  very  hyperopic 
when  the  lens  is  no  longer  in  the  axis  of  vision. 

Treatment.  The  best  treatment  of  a  slightly  dis- 
located lens  is  to  leave  it  alone,  unless  it  becomes  so 
opaque  as  to  decidedly  interfere  with  vision.  Where 
the  dislocation  is  very  marked,  or  where  the  lens  is 
loose  and  "bobs"  up  and  down  in  a  fluid  vitreous,  or 
where  it  is  dislocated  into  the  anterior  chamber,  it 
should,  as  a  rule,  be  removed.  The  successful  man- 
agement of  these  cases  requires  some  ophthalmologi- 
cal  experience,  and  the  operation  of  removal  often 
calls  for  the  exercise  of  considerable  skill  and  dexter- 
ity. 

APHAKIA.  Whenever  the  lens  is  absent,  whether 
as  the  result  of  operation,  absorption,  or  dislocation, 
the  condition  is  styled  aphakia.  The  refractive  power 
of  the  crystalline  being  equal  to  about  10  diopters 
(R.  8),  the  eye  is  made  hyperopic  to  that  extent,  and 


—  99  — 

after  cataract  operations,  as  is  well  known,  this  has 
to  be  taken  into  consideration  'and  suitable  glasses 
ordered. 

Moreover,  as  aphakia  necessarily  involves  a  loss 
-of  accomodative  power  (R.  13)  a  glass  for  reading 
and  other  near  work  is  required  in  addition  to  the 
distance  lens. 

CATARACT,  or  opacity  of  the  lens,  is  the  result  of 
structural  changes  in  the  fibres  of  which  it  is  com- 
posed. Sometimes  these  alterations  of  structure  are 
irregularly  distributed  throughout  the  body  of  the 
lens,  as  in  most  cases  of  senile  cataract;  sometimes 
they  are  mainly  central  (nuclear  cataract)  sometimes 
they  are  confined  to  the  periphery  or  cortex  (cortical 
cataract). 

There  is  a  great  variety  of  cataract,  but  the 
most  practical  division  of  them  is  into  "soft"  and 
"  hard  "  cataract.  Speaking  generally,  the  soft  variety 
occurs  in  persons  below  thirty  or  thirty-five  years  of 
age,  while  the  hard  variety  is  found  only  in  persons 
above  that  age. 

SENILE  CATARACT.  This  is  the  commonest  as 
well  as  the  most  important  form  of  the  disease.  The 
normal  lens  gradually  undergoes  changes  as  we  ad- 
vance in  years. 

In  old  age  the  lenticular  nucleus  oecomes  firmer, 
and  with  the  rest  of  the  lens  acquires  a  yellowish  tint 
and  transmits  less  light  than  formerly.  When  the 
pupil  is  widely  dilated  the  grayish,  translucent  outline 


of  the  whole  crystalline  is  distinctly  visible  both  by 
the  oblique  (9)  illumination  as  well  as  by  reflected 
light  (19).  While  these  changes  attendant  upon 
old  age  may  be  regarded  as  more  or  less  physiological, 
they  are  closely  allied  to  true  cataract.  In  the  latter 
instance,  however,  delicate  lines,  or  well  defined 
streaks  of  opacity,  best  seen  by  reflected  light  with  a 
dilated  pupil,  add  themselves  to  the  gray  tinge  of  the 
lens.  These  commonly  begin  at  the  periphery,  or 
equator,  and  gradually  invade  both  cortex  and  nucleus 
until  the  whole  crystalline  is  involved.  The  pictures 
made  by  progressive  senile  cataract,  from  the  time 
when  the  first  faint  dark  lines  appear  until  the  catar- 
act is  complete,  are  often  very  pretty  and  remind  one 
of  the  geometrical  shapes  one  sees  when  snowflakes 
are  examined  by  a  lens. 

The  time  occupied  by  the  process  varies  greatly 
but  may  extend  over  many  years. 

Symptoms.  Sight  will  not  be  much  affected  until 
the  nucleus  is  involved.  The  patient  then  complains 
that  images  are  distorted  or  multiplied  (polyopia),  or 
that  there  is  a  cloud  or  floating  bodies  before  the 
eyes.  This  fogginess  increases  very  slowly  until 
finally  the  visual  acuity  (12)  is  reduced  to  the  count- 
ing of  figures. 

When  cataract  is  ripe  or  mature  the  whole  lens  is 
opaque  and  it  can  be  safely  removed  by  operation. 
Such  a  cataract  should  have  a  regular  mother-of- 
pearl  appearance  by  the  oblique  illumination  (9),  and 


TOI    

while  this  examination  is  being  made  (the  pupil  un- 
dilated]  the  iris  should  not  cast  a  shadow  on  the  lens 
surface.  There  should  also  be  no  glittering  sectors 
{Forster)  or  facets  brought  to  view  as  the  patient  is 
told  to  look  in  different  directions  during  the  examin- 
tion.  When  an  operation  is  undertaken  on  an  imma- 
ture cataract  soft  matter  is  almost  certain  to  remain 
behind.  These  small  masses,  when  left  behind,  are 
not  only  liable  to  set  up  iritis,  but,  transparent  at  first, 
finally  become  opaque  and  lower  the  visual  acuity. 
Finally,  there  should  be  no  "red  reflex"  (20)  to  be 
seen. 

When  both  lenses  are  cataractous  the  patient  is 
-doomed  to  go  about  in  a  condition  of  practical  blind- 
ness for  months  unless  the  cataracts  are  artificially 
ripened.  The  only  effective  method  of  bringing  this 
about  is  the  plan  of  Forster.  A  preliminary  iridect- 
omy  (92)  is  made  and  the  capsule  is  gently  and  care- 
fully rubbed  over  the  cornea  by  a  rubber  spoon  (95). 
Or  if  it  be  decided  not  to  do  an  iridectomy  (8)  the 
same  massage  may  be  accomplished  by  first  tapping 
the  anterior  chamber  (73).  In  a  few  weeks  the  lens 
will  be  found  to  be  mature. 

REMOVAL  OF  SENILE  CATARACT.  Before  attempt- 
ing the  operation  of  extraction — the  only  efficient 
treatment  of  this  form  of  cataract — certain  important 
precautions  must  not  be  forgotten: 

1.  The  cataract  should  be  mature. 

2.  The  patient's  health  should  be  fairly  good, 


else  the  healing  process  may  be  interfered  with.  As 
hard  cataract  occurs  in  old  people,  who  are  not  as  a 
rule  robust,  we  may  have  to  deal  with  some  cases  who- 
are  not  encouraging  subjects  for  any  kind  of  surgical 
treatment.  It  is  wise  to  make  the  best  of  such  pa- 
tients and  to  improve  their  condition  as  far  as  it  is- 
capable  of  improvement.  Cough,  constipation,  and  in- 
somnia should  be  relieved  if  they  be  present. 

3.  The  external  eye  should  be  examined.     Mucc* 
cele  (50),  blepharitis  (34),  conjunctival  (M.  15)    and 
corneal  diseases  should  be  treated  and,  if   possible, 
cured   before   operation.      If   this   is   neglected,  the 
abundant  germs  which  these  diseases  supply  are  very 
likely  to  infect  the  corneal  wound  and  lead  to  dreaded 
complications. 

4.  Corneal  opacities  should  be  searched  for,  and, 
if  found,  the  patient  should  be  warned  that  they  form 
a  bar  to  realization  of  perfect  vision. 

5.  It  is  very  important,  in  view  of  their  ultimate 
effect  upon  the  visual  acuity,  that  the  presence  or 
absence  of  deep-seated  disease  of  the  eye  should  be 
demonstrated.     It  would  be  very  disappointing,  after 
an   operation    entirely    successful    from    a    surgical 
standpoint,  to -find  that  the  patient  had  had  all  the 
while  disease  of  the  optic  nerve,  for  example,  and  was 
unable  to  see  any  better  after  the  extraction  than 
before  it.     Such  a  case  came  under  my  observation, 
not   long  ago,  where   the  examinations  about  to  be 
described  were  omitted.     In  a  case  of  uncomplicated 


—  103  — 

cataract,  then,  the  patient  should  have  prompt  per- 
ception of  light — should,  in  other  words,  be  able  to 
state  at  once  when  the  hand  is  passed  over  his  eye 
between  it  and  a  good  window  light.  In  a  dark 
room  he  should  be  able  to  see  a  candle  flame  20  feet 
away,  or  a  faint  light  reflected  from  a  mirror  (20)  at 
a  metre's  distance,  and  to  point  out  its  locality  when 
moved  about  in  different  directions.  This  "  projec- 
tion of  light  "  test  should  never  be  neglected.  It  is 
really  a  test  of  the  perceptive  ability  of  the  different 
sections  of  the  retina,  and  fails  when  any  consider- 
able part  of  the  latter  is  diseased. 

There  are  almost  as  many  forms  of  cataract  ope- 
rations as  there  are  operators,  but  the  usual  method 
of  extracting  senile  cataract  is  the  so-called  modified 
peripheral  linear  operation  of  Von  Graefe.  The 
instruments  needed  are  a  pair  of  fixation  forceps 
(Fig.  16),  a  wire  lid  speculum  (Fig.  15),  a  narrow 
Graefe  cataract  knife  (Fig.  17), — whose  well  sharpened 
point  pierces  readily,  and  by  its  own  weight,  the  test- 
ing drum  (Fig.  24),  a  pair  of  iris  forceps  (Fig.  21),  a 
metal  or  shell  iris  repositor,  a  pair  of  iris  scissors,  and 
the  cystitome  (Fig.  25.) 

Examine  them  with  a  lens  and  be  sure  that  they 
are  perfectly  bright,  sharp,  and  clean.  One  drop  of  a 
freshly  prepared  4  per  cent,  solution  of  cocaine  is 
dropped  into  the  eye  every  minute  for  five  minutes. 
The  speculum  is  now  introduced  by  sliding  the  upper 
branch  under  the  upper  lid,  and  then  the  lower  end 


—  IO4  — 

under  the  lower  lid.     It  should  not  be  opened  too 
widely  lest  it  cause  pain. 


FIG.  24. 

The  patient  should  now  be  warned  not,  under 
any  circumstances,  to  "  squeeze  the  lids  together  " 
during  the  operation.  It  would  also  be  well  to  exer- 
cise him  beforehand  in  looking  down,  up,  in  and  out. 
Whether  it  be  from  "operation-terror"  or  what  not, 
some  patients  cannot  be  induced  to  perform  these 
simple  acts  at  those  critical  moments  when  they  are 
urgently  called  for.  A  little  preliminary  drill  will  be 
found  useful  in  such  cases. 


lEMANN&CO. 


FIG.  25. 

The  first  step  is  the  corneal  incision.  This  should 
be  made  at  the  limbus  in  the  upper  corneal  semicircle, 
and  will  involve  about  two-fifths  (better  more  than 
less)  of  the  whole  circumference,  as  in  Fig.  26.  The 


patient  looking  up,  the  conjunctiva  and  subconjunc- 
tival  tissue  are  grasped  as  represented.  He  now  looks 
down,  and  the  point  of  the  knife,  edge  up,  is  entered, 
and  is  directed  downwards.  The  handle  is  depressed 
and  a  counter  puncture  is  made,  and,  by  a  to  and  fro 
motion,  the  blade  cuts  its  way  out,  as  along  the  dotted 
Jine  of  the  diagram. 


FIG.  26. 

The  second  step — the  iridectomy — has  been  already 
described  (92). 

The  third  step  is  the  opening  of  the  capsule  to 
-allow  of  the  escape  of  the  lens.  As  soon  as  all  bleed- 
ing stops  the  patient  looks  down,  the  surgeon  again 
fixes  the  globe,  the  cystitome  (Fig.  25)  is  introduced, 
and  crucial  scratches  are  gently  and  carefully  made 
on  the  cataract  surface. 


—    106  — 

The  fourth  step.  After  the  cystotomy  the  lens 
will  probably  present  in  the  wound,  and  its  complete 
delivery  may  be  accomplished  (the  patient  looking 
down)  by  gently  pressing,  midway  between  the  centre 
and  the  lower  edge  of  the  cornea,  with  the  rubber 
spoon.  The  pressure  should  be  directly  backwards, 
and  no  attempt  ought  to  be  made  to  squeeze  out  the 
lens  by  even  the  appearance  of  force.  Loss  of  vitre- 
ous is  apt  to  occur  unless  this  precaution  is  observed. 
The  opaque  lens  may,  however,  be  •'  followed  up  "  by 
the  spoon  as  it  emerges  from  between  the  lips  of  the 
wound.  Here  the  assistant  will  loosen  the  fixation 
forceps,  and  the  speculum  had  better  be  removed. 

Fifth  step.  It  is  proper  to  coax  out,  by  stroking 
the  cornea  from  below  upward,  any  masses  of  soft 
matter  or  pieces  of  capsule  that  may  have  been  left  be- 
hind. The  pupil,  which  was  before  white,  is  now  black, 
and  these  remains  can  usually  be  seen.  When  the 
edges  of  the  iris  coloboma  are  in  their  proper  places, 
and  everything  (iridic,  lenticular,  and  capsular  remains,, 
vitreous,  blood-clots,  etc.)  removed  from  between  the 
edges  of  the  wound — some  surgeons  employ  boric 
acid  irrigation  for  the  purpose — the  lids  are  gently 
closed. 

DRESSINGS  innumerable  have  been  recommended 
after  cataract  operations.  While  it  is  well  not  to  fol- 
low empirically  any  one  plan,  I  would  advise  the 
following:  A  small  piece  of  old,  aseptic  linen,  cut  so- 
as  to  fit  the  oculo-nasal  angle,  is  thinly  spread  with 
this  ointment: 


—  107  — 

Finely  powdered  boric  acid 3  j. 

Atropine  sulph ». . .  gr.  ij. 

Cold  cream |  j 

It  is  then  evenly  applied  to  the  closed  lids.  Next,  a 
thin  layer  of  borated  cotton,  and  over  all  a  flannel 
bandage  (29).  If  the  patient  will  keep  moderately 
quiet,  there  is  no  necessity  for  confining  him  to  a  dark 
room,  or  even  putting  him  to  bed.  A  shade  over  the 
eyes,  and  a  comfortable  high-backed  arm-chair,  are 
much  to  be  preferred  to  the  dark  room,  confinement 
to  bed,  and  absolute  quiet  of  the  old  regime. 

The  first  night  a  dose  of  sulphonal,  2  grammes 
(30  grains)  two  hours  before  retiring,  with  ^  grain  of 
morphia  just  before  the  usual  hour  of  sleep,  may  be 
administered. 

The  after-treatment  is  important.  During  the 
twenty-four  hours  succeeding  cataract  extraction, 
most  patients  complain  of  smarting  or  occasional 
twitches  of  pain.  These  have  no  serious  significance, 
and  are  usually  relieved  by  the  morphia  given  at 
night.  If  the  eye  feels  perfectly  comfortable  the 
bandage  may  be  left  until  the  third  or  fourth  day. 
As  a  rule,  however,  the  patient  will  be  more  at  ease  if 
his  closed  lids  are  bathed  cautiously,  daily,  with  warm 
boric  acid  lotion,  and  fresh  dressings  applied.  He  is 
not  in  that  case  tempted  to  rub  his  itching  lids  or 
brow,  to  the  detriment  of  the  healing  process,  as  is 
sometimes  the  case  when  the  eye  remains  untouched 
for  several  days.  If  all  goes  well,  glasses  for  reading 


—  io8  — 

as  well  as  for  distant  vision  can  be  ordered  in  about 
six  weeks.        * 

COMPLICATIONS. — Continued  dull  pain  after  the 
first  twenty-four  hours,  or  excessive  discharge,  usually 
means  mischief  and  should  lead  to  a  removal  of  the 
bandage  and  a  critical  examination  of  the  eye.  These 
signs,  when  they  occur  during  the  first  three  or  four 
days  after  the  operation,  point  to  the  invasion  of  the 
corneal  cut  by  micro-organisms.  Later  on — five  to 
ten  days — they  mean  iritis.  In  the  first  instance,  puru- 
lent infiltration  of  the  edges  of  the  wound  is  indicated 
by  a  grayish  yellow  appearance  along  the  line  of  the 
incision.  As  soon  as  it  is  discovered,  the  eye  should 
be  well  irrigated  with  hot  boric  acid  solution,  and  the 
cautery  thoroughly  applied  to  the  line  of  infection. 
The  hot  irrigations  ought  to  be  renewed  every  three 
or  four  hours  until  the  disease  is  under  control.  The 
secondary  iritis  has  the  signs  and  symptoms  of  the 
primary  form,  and  should  be  treated  like  it  (90). 

EXTRACTION  WITHOUT  IRIDECTOMY  is  an  old 
friend  with  a  new  face.  Practiced  more  than  a  quarter 
of  a  century  ago,  it  fell  into  desuetude,  but  has  lately 
been  revived  and  has  many  renowned  advocates.  It 
cannot  be  denied  that  other  things  being  equal  the 
preservation  of  a  round,  central,  and  more  or  less 
contractile  pupil  is,  in  cataract  extraction,  a  consum 
mation  devoutly  to  be  wished.  On  the  whole  this 
operation  is  more  difficult  to  perform  than  the  fore- 
going. Whether  this  drawback  is  offset  by  superior 


—  109  — 

advantages  in  the  way  of  better  vision,  a  natural  ap- 
pearance of  the  pupil,  absence  from  complications, 
etc.,  remains  just  now  a  debated  question.  Probably, 
as  Noyes  suggests,  it  is  better  not  to  do  exclusively 
either  operation,  and  there  certainly  appears  no  reason 
why  we  may  not  come  to  employing  the  "  simple  " 
method  for  ordinary  cases  and  adding  the  iridectomy 
when  good  and  sufficient  reasons  call  for  it. 

SOFT  CATARACT  occurs  in  children  and  young 
adults  (99).  The  most  important  variety  is  the 
lamellar  or  zonular.  This  is  the  ordinary  cataract  of 
infancy  and  childhood  and  is  either  congenital  or 
forms  soon  after  birth.  It  can  easily  be  made  out 
through  the  dilated  pupil,  both  by  oblique  illumination 
(9)  and  reflected  light  (20).  The  opacity  effects  the 
lens  in  layers,  does  not  extend  to  the  periphery,  and 
the  visual  acuity  is  sometimes  as  high  as  f$  (12). 

Lamellar  cataract  is  not  progressive  like  the 
senile  variety. 

A  history  of  infantile  fits  is  almost  always  given  by 
these  patients;  they  nearly  all  have  "  strumous  "  teeth, 
that  is,  the  enamel  of  the  incisors  and  canines  is  likely 
to  be  absent  from  the  crowns  and  upper  halves,  and 
(in  England  especially)  they  almost  all  are  certain  to 
have  been  treated  during  the  teething  period  with 
mercurials.  What  the  relation  is,  if  there  be  any, 
that  exists  between  the  cataract,  the  convulsions,  the 
rachitic  teeth  and  the  mercurial  treatment  it  is  diffi- 
cult to  say. 


—   no  — 

In  addition  to  the  different  forms  of  congenital 
and  infantile  cataract  traumatic  cataract  is  of  the  soft 
variety.  The  injury  brings  about  rupture  of  the  an- 
terior capsule;  contact  of  the  aqueous  humor  with  the 
normal  lens  causes  its  fibres  to  swell,  become  opaque, 
project  through  the  rent  in  the  capsule  and  some- 
times, as  in  the  operation  for  discission  (in),  to  be- 
come partially  or  totally  absorbed. 

Diabetic  cataract  is  also  of  the  soft  variety. 

Treatment.  If,  as  in  some  cases  of  lamellar  cat- 
aract, the  patient's  vision  be  sensibly  improved  by 
dilatation  of  the  pupil,  an  optical  iridectomy  (93)  is 
indicated.  If,  however,  with  correction  of  optical 
errors,  this  does  not  furnish  a  useful  degree  of  sight, 
or  if  the  cataract  be  total,  needling  or  DISCISSION  is 
called  for.  This  operation  is  employed  when  absorp- 
tion of  the  whole  lens  is  sought  to  be  secured. 

The  pupil  having  been  previously  dilated  with 
weak  atropine  solution,  cocaine  is  instilled  (or,  in  the 
case  of  quite  young  children,  chloroform  given)  and  a 
"stop  "  cataract  needle  (Fig.  27)  is  passed  through  the 


SHnPPJSMITH 


FIG.  27. 

cornea  2  mm.  from  the  outer  scleral  junction.  The 
point  is  now  directed  forwards  to  the  centre  of  the 
lens  and  a  single  vertical  cut  made  in  the  capsule. 
The  needle  is  at  once  withdrawn,  little  or  no  aqueous 


—  Ill  — 

escapes  and  there  is  very  little  inflammatory  reaction. 
In  a  day  or  two  a  portion  of  the  lens  will  project 
through  the  opening  thus  made.  This,  through 
the  solvent  action  of  the  aqueous,  will  be  ab- 
sorbed; another  piece  will  protrude,  go  through  the 
same  process,  and  so  on,  until  in  from  three  weeks  to 
three  months  the  whole  lens  will  have  disappeared. 
Weak  atropine  drops  should  be  used  throughout  and 
a  bandage  is  advisable.  Some  surgeons  prefer,  as 
soon  as  the  lens  mass  comes  forward  into  the  anterior 
chamber,  to  remove  it  by  means  of  a  specially  con- 
structed suction  syringe,  but  the  discission  operation 
alone  is  usually  all  that  is  required. 

Needling  in  Secondary  Cataract. — The  posterior 
capsule  is,  of  course,  not  removed  in  either  of  the 
cataract  operations  just  described,  and  if  at  all 
opaque,  its  presence  may  prevent  the  patient  from 
obtaining  good  vision.  Fine  fibrous  threads  and  iritic 
remains  are  also  occasionally  left  after  the  primary 
operation.  A  central  rent  should  be  made  in  the 
opaque  curtain,  and  this_is  best  done  by  introducing 
two  discission  needles — one  in  each  hand— at  the 
outer  and  inner  corneal  borders  respectively,  and  hav- 
ing them  meet  in  the  centre  of  the  capsule;  the 
handles  are  simultaneously  elevated  so  as  to  cut  the 
desired  opening.  Even  when  the  capsular  cataract 
can  only  be  made  out  with  the  lens  (9),  a  consider- 
able increase  in  the  visual  acuity  is  attained  by  this 
operation  of  needling,  and  it  is  commonly  resorted  to. 
No  reaction  should  follow. 


LESSON  VIII. 

GLAUCOMA. 

The  Necessity  of  an  Early  Diagnosis — Varieties — Causes — 
Intraocular  Changes  in  the  Disease — Signs  and  Symp- 
toms— Treatment — Iridectomy  and  Sclerotomy — Es- 
erine. 

In  the  chapter  on  iritis  some  stress  was  laid  upon 
the  fact  that  to  mistake  that  disease  for  some  other 
affection,  conjunctivitis  for  example  (M.  15),  as  was 
not  uncommonly  done,  was  to  fall  into  an  error  fraught 
with  disaster  to  patient  and  doctor.  A  similar  state- 
ment, even  more  strongly  accentuated,  might  be 
made  about  glaucoma.  In  its  acute  form  it  proceeds 
to  destruction  of  vision  in  a  very  short  time,  and  even 
the  chronic  types  are  distinctly  progressive  in  charac- 
ter. It  is  usually  a  disease  of  the  intraocular  lymph- 
atic system.  The  interior  lymph  stream  arises,  broadly 
speaking,  from  the  blood-vessels  of  the  ciliary  body 
and  iris,  flows  from  the  posterior  chamber  through 
the  pupillary  opening,  and  empties  into  the  canal  of 
Schlemm  (8)  at  the  angle  formed  by  the  iris  and 
sclera.  It  is  easy  to  understand  how  anything,  such 
as  pressure  upon  this  canal  by  the  enlarged  lens  of 
old  age,  extensive  posterior  synechias  (87),  increased 
secretion  of  aqueous,  dislocation  of  the  lens  (97),  etc., 
which  interferes  with  the  outlet,  or  abnormally  in- 
creases the  inflow,  of  this  lymphatic  fluid,  may  bring 


-  H3  — 

about   a   high    ocular    tension    and    produce    glau- 
coma.* 

The  local  effects  of  the  disease  are  those  of  intra- 
ocular pressure.  The  eyeball  grows  harder,  and  the 
tension  (9)  may  so  increase  that  it  feels  like  a  small 
apple  under  the  fingers,  barely  capable  of  indentation. 
The  optic  nerve,  where  it  joins  the  globe,  is  found 
to  be  pressed  out  or  excavated,  and  if  the  pressure  is 
long  continued  it  atrophies.  The  lens  is  pushed  for- 
ward so  as  to  diminish  the  depth  of  the  anterior 
chamber,  and  the  cornea  may  be  cedematous  and 
hazy. 

Glaucoma  occurs  most  frequently  in  persons  over 
45  years  of  age,  and  is  generally  found  in  hyperme- 
tropes,  the  small  eyeball  of  the  latter  being  held  by 
some  to  predispose  to  the  disease. 

Diagnosis.  —The  following  symptoms  and  signs 
should  ever  be  borne  in  mind  in  making  an  examina- 
tion of  the  eyes  of  persons  over  40  years  of  age,  for  it 
must  be  remembered  that  the  usual  (acute  simple) 
form  of  this  affection  is  readily  diagnosed  if  a  little 
care  be  exercised. 

In  the  acute  "congestive"  form  the  eye  is  red — 
as  in  iritis — and  nearly  all  the  other  symptoms  will  be 
well  marked.  In  the  chronic  forms,  which  may  last 
for  years,  there  are  intervals  of  remission,  during 
which,  beyond  a  slight  lowering  of  vision,  nothing 

*  From  y\av/co$,  green — referring  to  the  greenish  ap- 
pearance of  the  pupil. 
8  zz 


abnormal  can  be  remarked.  Repeated  attacks,  how- 
ever, combine  to  destroy  sight,  and  finally,  if  the  pa- 
tient live  long  enough  and  unless  relief  is  meantime 
given,  the  glaucoma  becomes  "absolute"  and  com- 
plete blindness,  through  atrophy  of  the  optic  nerve,  is 
the  result. 

1.  The  tension  (9)  is  increased. 

2.  The  pupil  is  oval  and  dilated,  and  has  a  greenish 
tinge. 

3.  Vision  is  impaired,  recently,  progressively  and 
rapidly  in  the  acute  forms. "    There   will  be  a  history 
of  periods  of  ^improved  sight  in  the  chronic  cases. 

4.  There  is  always  pain  (in  acute  cases  of  a  neu- 
ralgic character),  usually  referred  to  the  branches  of 
the  fifth  nerve.     In  the  chronic  cases  the  pain  is  dull 
and  may  be  confined  to  the  globe.    These  pains  often 
get  worse  at  night. 

5.  Rainbows,  fogs  and  haloes  about  gas,  lamp  ana 
candle  lights  are  seen  by  the  glaucomatous  subject. 
This  symptom  is  produced  by  the  rays  of  light  com- 
ing through  the  oedematous  cornea,  and  is  practically 
the  same  appearance  that  one  sees  on  looking  at  a 
light  through  a  glass  that  has  been  breathed  upon. 

6.  The  cornea  is  o/ten  hazy.     When  decidedly  so, 
it  will  usually  be  found  to  be  anaesthetic,  as  proved 
by  touching  it  with  a  camel's  hair  pencil. 

7.  The  anterior  chamber  is  shallower  than   normal 

(7). 

8.  Congestion  of  the  episcleral  veins  is  rarely  absent, 


-even  in  chronic  glaucoma,  and  is  probably  a  passive 
condition,  the  result  of  impeded  circulation  within 
the  eye. 

Treatment. — The  acute  congestive  form  calls 
urgently  for  treatment  which  will,  if  given  early,  be 
wonderfully  efficacious.  The  pains  will  be  relieved, 
the  vision  will  improve,  and  after  the  glaucomatous 
*"  storm  "  is  over  the  eye  may  become  almost,  if  not 
quite,  natural  again.  This  treatment  is  a  broad  and 
quite  peripheral  iridectomy  (93).  In  acute  cases — 
when  the  eye  is  painful  and  sensitive — cocaine  is  not 
absorbed  and  is  not  an  efficient  anaesthetic;  some  sur- 
geons accordingly  give  chloroform  or  ether. 

Some  operators  prefer  sclerotomy.  The  pupil  is 
first  thoroughly  contracted  with  eserine,  and  an  in- 
cision like  that  for  cataract  extraction  (105)  is  made, 
but  well  within  the  sclera.  It  is  not  completed,  but  a 
bridge  of  scleral  tissue  about  2  mm.  in  width  is  al- 
lowed to  remain.  This  prevents  prolapse  of  the  iris. 
In  sclerotomy  a  certain  amount  of  drainage  is  assumed 
to  take  place  through  the  scleral  scar,  and  thus  to 
relieve  the  intra-ocular  pressure.  The  peripheral 
iridectomy  relieves  the  choked  canal  of  Schlemm. 

Two  things  are  especially  to  be  remembered  in 
connection  with  these  operations:  First,  that  operating 
on  one  eye  is  apt  to  precipitate  (not  produce)  an  at- 
tack in  the  other  eye;  and,  second,  that  the  relief 
given  to  the  intra-ocular  pressure  may  be  the  cause  of 
bleeding  (into  the  interior  chamber  and  vitreous) 


—  n6  — 

from  weak  and  (now)  unsupported  vessels.  Vitreous 
haemorrhage  is  to  be  feared,  as  when  it  is  extensive  it 
may  lead  to  final  destruction  of  the  eye. 

Bleeding  into  the  anterior  chamber  is  not  of  seri- 
ous importance.  Chronic  and  subacute  glaucoma  is 
often  treated  by  eserine  and  pilocarpine,  either  alone 
or  as  an  adjunct  to  iridectomy  or  sclerotomy,  but  in 
the  acute  and  sub-acute  forms  an  operation  is  urgently 
called  for. 

These  drugs  contract  the  pupil  and  relieve  the 
obstructed  drainage  by  dragging  a  portion  of  the  iris 
away  from  the  clogged  "  angle  of  filtration."  Mydri- 
atics  like  atropine,  on  the  other  hand,  increase  the 
tension  by  pushing  the  mass  of  the  iris  towards  its 
periphery  and  so  preventing  drainage.  They  shouldr 
therefore,  never  be  prescribed  in  glaucoma.  Moreover, 
in  old  people,  it  is  wise  to  determine  the  degree  of 
ocular  tension  before  prescribing  mydriatics. 

Still  more  important  is  it  that  the  surgeon  shall 
always  be  certain  that  the  case  of  "iritis,"  for  which 
he  is  prescribing  atropine,  is  not  one  of  acute  or 
"  congestive"  glaucoma. 

Ordinary  care,  combined  with  a  knowledge  of 
the  symptoms  and  signs  proper  to  both  diseases,  will 
prevent  such  a  lamentable  error. 


LESSON  IX. 

OCULAR  AFFECTIONS  IN  GENERAL  DISEASES. 

Manifestations  of  Syphilis,  Rheumatism,  and  Other  Dia- 
theses— Muscae  Volitantes — Amblyopia — Toxic  Ambly- 
opia — Eye  Symptoms  in  Tobacco  and  Alcohol  Poison- 
ing— Abscess  of  the  Orbit — Graves'  Disease — Progres- 
sive Locomotor  Ataxia — Diphtheria — Bright's  Disease 
—  Migraine  —  Malaria  —  Reflex  Neuroses — Sympathetic 
Ophthalmia — Penetrating  Wounds  of  the  Globe — Sympa- 
thetic Irritation  and  Inflammation — Treatment — Enu- 
cleation  of  the  Eyeball. 

Many  scrofulous,  syphilitic,  tubercular,  rheu- 
-matic,  and  gonorrhaeal  affections  of  the  eye  have 
-been  spoken  of  in  these  pages.  In  addition  to  these 
local  manifestations  of  constitutional  diatheses,  there 
-are  certain  signs  and  symptoms  exhibited  by  the 
visual  apparatus  and  complained  of  by  the  patient, 
whose  origin  lies  remote  from  the  organ  of  sight,  that 
do  not  indicate  organic  ocular  disease  at  all,  or  point 
•only  to  a  partial  or  secondary  involvement  of  the  eye. 
These  facts  continually  teach  us  that  a  true  special- 
ism is  that  which  regards  the  organism  as  a  whole, 
and  he  who  would  successfully  treat  the  diseases  of 
one  part  of  it  must  ever  cast  side  glances  at  the  con- 
dition of  the  other  organs  and  tissues.  Some  of  these 
ocular  signs  of  remote  disease  will  now  be  considered. 

MUSC/E  VOLITANTES.  Patients  not  infrequently 
•complain  of  small  bodies  floating  across  the  field  of 


—   n8  — 

vision.  They  are  especially  noticeable  when  looking 
at  the  sky,  or  at  some  other  bright  background,  when 
dark  threads  or  spots  dart  like  insects  (musccz)  in 
front  of  the  eye.  These  appearances  are  due  to  min- 
ute vitreous  specks  which  almost  every  normal  eye 
possesses.  When  the  health  is  poor,  the  digestion 
bad,  the  circulation  weak  or,  in  woman,  when  the  re- 
productive organs  are  diseased,  these  minute  bodies  in 
the  vitreous  humor  may  make  their  presence  felt,  and 
although  they  do  not  interfere  with  vision  they  yet 
give  rise  to  a  good  deal  of  complaint.  In  addition  to- 
this  condition,  however,  it  must  be  remembered  that 
the  vitreous  may  become  diseased  and  infiltrated  with 
small  opacities  which  not  only  lower  the  visual  acuity 
but  produce  permanent  muscce.  These  floating  bodies 
are  readily  detected  by  the  examination  with  reflected 
light  (20).  The  patient  looks  slowly  in  various  direc- 
tions and  then  at  the  mirror,  the  observer's  gaze  being 
directed  at  the  pupil.  The  dark  bodies  rise  and  fall 
with  the  motion  of  the  globe  and  are  seen,  especially 
when  the  pupil  has  been  dilated,  to  move  across  the 
bright  field  of  the  "red  reflex." 

Pathological  vitreous  opacities  are  often  the  re- 
mains of  effused  blood  or  they  may  be  produced  by 
inflammation  (hyalitis)  of  the  corpus  vitreum  itself. 
They  may  also  arise  from  injury  or  as  a  sequence  of 
disease  of  the  choroid  and  other  deep  structures  of 
the  eye. 

Treatment  is  of  little  avail  except  in  those  cases- 


aggravated  by  a  lowering  of  the  systemic  tone.  Gen- 
eral treatment  in  such  cases  often  brings  relief.  Where 
the  muscae  are  manifest  from  uterine,  hepatic,  or 
other  affections  the  duty  of  the  physician  is  obvious. 

AMBLYOPIA.  This  term  belongs  to  the  pre-oph- 
thalmoscopic  period  of  ophthalmology,  but  it  still  sur- 
vives to  describe  certain  diseases  whose  chief  symp- 
tom is  deficient  vision  without  constant  and  evident 
organic  lesion.  Amblyopia  is  sometimes  congenital 
and  is  then  probably  due  to  deficient  development  of 
some  part  of  the  optic  tract.  Or  it  may  arise  from 
simple  non-use  of  the  eye,  as  in  squint  (141).  Hence 
the  term  Amblyopia  ex  anopsid.  There  is  an  important 
variety  of  this  affection  whose  symptoms  every  prac- 
titioner is  likely  to  meet  with  sooner  or  later,  although 
it  is  by  no  means  a  common  disease.  I  refer  to  the 
visual  disturbances  produced  by  certain  (intoxicant) 
poisons,  especially  alcohol  and  tobacco. 

Toxic  AMBLYOPIA.  This  disease  'is  pathologic- 
ally (Uhthoff)  an  interstitial  neuritis,  affecting  prefer- 
ably the  macular  fibres  of  the  optic  nerve  and  closely 
resembles  those  neuritic  processes  which  one  sees  in 
the  peripheral  nerves  of  patients  suffering  from  aggra- 
vated forms  of  chronic  alcoholism.  It  is  now  gener- 
ally admitted  that,  so  far  as  the  optic  nerve  is  con- 
cerned, tobacco  may  also  produce  such  a  true  chronic 
retro-bulbar  neuritis;  indeed  most  English  observers 
claim  that  nicotine  and  not  alcohol  is  responsible  for 
the  result.  The  association  of  the  two.  poisons  in 


bringing  about  the  morbid  changes  is  the  commoner 
experience.  The  disease  almost  invariably  attacks 
men  above  40  years  of  age  and  affects  both  eyes. 

The  symptoms  are  characteristic  and  consist  chief- 
ly of  a  complaint  that  vision  is  cloudy  or  foggy.  The 
usual  story  is  that  a  '''mist"  appears  to  hang  about 
objects  upon  which  the  patient  fixes  his  gaze.  Read- 
ing fine  print  becomes  difficult  or  impossible;  the 
vision  is  lowered,  often  markedly  so  (f§  or  f$);  there 
is  a  general  atonic  condition,  some  insomnia,  anorexia 
and  there  may  be  a  dull  frontal  pain.  This  complaint 
made  by  a  constant  smoker  (or  drinker)  over  40  years 
of  age  should  at  once  arouse  the  suspicions  of  the 
practitioner.  An  examination  of  the  vitreous  will 
be  in  order  to  make  certain  that  the  "fogginess" 
is  not  due  to  opacities  in  that  medium,  and  the  lens 
(100)  to  be  sure  that  there  is  no  commencing  cataract. 
But  the  test  par  excellence  is  the  examination  of  the 
color  sense  (14)  or  the  field  of  vision  for  color. 

Take  a  single  thread  of  bright  red  Berlin  wool  and 
double  it  between  the  thumb  and  finger  of  the  right 
hand,  holding  it  so  that  only  a  quarter  of  an  inch  of 
the  loop  projects  and  is  seen.  Cover  the  patient's  left 
eye  with  a  bandage,  and  stand  in  front  of  him  so  that 
he  can  fix  the  examiner's  right  eye  at  a  distance  of  a 
few  feet.  Now  interpose  the  small  piece  of  red  wool. 
When  placed  directly  between  the  two  right  eyes,  the 
patient  will  not  recognize  it  as  red  (or  the  red  color 
will  be  indistinct)  until  it  is  moved  two  or  three 


121    — 

inches  to  the  right,  left,  up  and  down  from  the  line 
joining  the  two  eyes.  The  same  result  will  be 
obtained  from  green  wool,  but  probably  not  from 
white,  blue  or  yellow  unless  the  disease  is  far 
advanced  and  the  visual  acuity  lower  than  (12)  ^fo. 
In  other  words,  the  existence  of  a  central  scotoma 
for  red  and  green  has  been  demonstrated — the  char- 
acteristic sign  of  toxic  amblyopia. 

Prognosis  is  favorable,  unless  the  vision  has  been 
less  than  ^Vir  f°r  a  considerable  time  before  applying 
for  treatment.  Taken  in  time,  perfect  recovery  will 
follow  an  observance  of  the  following  rules:  ist, 
total  and  immediate  abstinence  from  the  use  of 
tobacco  and  alcohol.  2d,  Treatment  of  the  general 
health,  good  food,  etc.  3d,  The  administration  of 
medium  doses  of  iron  and  strychnia  by  the  mouth, 
and  single  daily  (if  possible)  hypodermic  injections  of 
strychnia.  The  dose  of  strychnia  et  per  orem  et  sub 
cutem  is  to  be  slowly  increased. 

The  diagnosis  once  correctly  made,  this  routine 
treatment  can  be  prescribed  with  the  assurance  that, 
if  faithfully  followed,  a  cure  may  be  confidently 
expected  in  from  one  to  three  months.  A  guarded 
diagnosis  will,  of  course,  be  given  when  the  case  is 
very  chronic  and  vision  is  greatly  lowered. 

ORBITAL  ABSCESS.  Pus  within  the  orbit  may 
have  various  origins,  (i)  It  may  break  through  from 
the  frontal  sinus;  (2)  from  a  carious  tooth;  (3)  from  a 
tonsillar  abscess:  (4)  it  may  be  an  extension  of  facial 


erysipelas;  (5)  it  may  follow  an  attack  of  cellulitis- 
due  to  many  causes,  such  as  injury,  etc.;  (6)  it  may 
follow  syphilitic  and  strumous  orbital  periostitis;  (7) 
the  abscess  may  be  metastatic.  In  the  acute  forms 
of  cellulitis  and  periostitis  we  notice  that  the  ocular 
excursions  are  limited,  the  eye  is  more  or  less  dis- 
placed, the  conjunctiva  is  chemosed,  while  the  lids 
are  thickened,  puffy  and  red.  If  the  disease  be  near 
the  margin  of  the  cavity,  pain  will  be  severe  and  ten- 
derness is  usually  well  marked.  If  deep,  there  will 
be  evening  rise  of  temperature,  chills,  and  the  other 
symptoms  of  septic  absorption.  As  it  is  difficult  to 
say  just  where  pus  has  formed,  an  exploring  needle 
should  be  used  if  there  is  doubt.  The  abscess  sooner 
or  later  points  somewhere  between  the  globe  and  the 
rim  of  the  orbit,  and  should  be  opened  through  the 
conjunctiva  with  a  long  and  narrow  knife  at  as  early 
a  date  as  possible.  The  pus  cavity  should  be  thor- 
oughly washed  out  and  a  drainage  tube  inserted. 
Free  drainage  must  be  maintained  at  all  hazards  and 
the  possibility  of  cerebral  complications  not  forgot- 
ten. If  there  be  periostitis  of  specific  origin,  consti- 
tutional treatment  should  be  given.  When  the  dis- 
ease lies  deep  and  relief  is  not  obtained  early,  the 
optic  nerve  may  atrophy  from  pressure. 

Fistulous  openings,  the  result  of  a  partially  cured 
abscess,  should  be  treated  like  fistula  elsewhere. 

EXOPHTHALMIC  GOITRE.  .  Graves'  or  Basedow's 
disease.  In  addition  to  the  fast  pulse,  enlarged  thy- 


—  123  — 

roid,  nervousness,  and  some  other  symptoms  of 
Graves'  disease  the  ocular  signs  are  very  important. 
Ninety  per  cent,  of  cases  occur  in  women.  The  ex- 
ophthalmos  (10)  may  be  well  or  slightly  marked.  It 
may  be  so  great  that  dryness  and  ulceration  of  the 
cornea  results  from  exposure  and,  during  sleeping 
hours,  the  eyelids  are  no  longer  able  to  cover  the 
projecting  globe. 

Graefes'  sign  is  almost  characteristic  of  the  dis- 
ease a.nd  is  not  only  one  of  the  earliest  but  one  of  the 
most  valuable  guides  to  diagnosis.  It  results  from 
the  impairment  of  the  consensual  movement  of  the 
eyeball  with  the  upper  lid.  In  healthy  persons  the 
lid  rises  and  falls  (the  palpebral  edge  always  preserv- 
ing the  same  relation  to  the  upper  corneal  margin)  as 
the  globe  rotates  upwards  or  downwards.  But  in 
Graves'  disease  this  relation  is  markedly  altered.  If 
the  patient  fix  the  observer's  finger  tip  at  two  feet, 
while  it  is  being  slowly  moved  from  above  the  pa- 
tient's head  downwards  in  front  of  his. face,  the  lid 
will  be  seen  to  follow  the  eye  for  a  short  distance  and 
then  begin  to  lag  behind  until  an  abnormal  portion  of 
the  sclerotic  is  visible  between  them. 

Dalrymples  (Swanzy)  sign  is  the  staring  appear- 
ance of  the  patient.  The  interpalpebral  aperture  is 
wider  than  normal  and  gives  rise  to  this  condition. 
.Cocaine  will  produce  a  similar  appearance;  hence  it 
is  that  some  observers  have  thought  that  Dalrymple's 
sign  is  caused  by  a  partial  anaesthesia  of  the  conjunc- 
tiva—a condition  which  is  sometimes  present. 


—   124  — 

Slellwag 's  sign  is  also  valuable  and  fairly  constant. 
It  consists  in  the  infrequency  of  winking.  The  act  is 
also  incomplete,  for  it  will  be  noticed  that  the  lid 
margins  do  not  touch.  Nictitation  occurs  once  in 
from  40  to  70  seconds  by  the  watch  instead  of  every 
20  or  30  seconds,  as  it  should. 

Prognosis.  As  Hulke  says,  in  exophthalmic  goitre 
we  have  the  rare  instance  of  a  disease  which  runs  an 
exceedingly  chronic  course  (lasting  for  years)  and  yet 
tends,  if  life  lasts,  to  get  entirely  well,  and  this  al- 
though ten  per  cent,  of  the  cases  succumb  to  inter- 
current  diseases.  So  far  as  the  eye  symptoms  are 
concerned  the  proptosis  (123)  does  not  often  disappear, 
although  it  usually  undergoes  marked  improvement. 
Tarsoraphy  (47)  may  be  performed  if  the  cornea  re- 
mains exposed  during  sleep. 

PROGRESSIVE  LOCOMOTOR  ATAXIA.  Tabes  dor- 
salis.  The  eye  symptoms  of  this  serious  disease  are 
extremely  important.  Vision  is  one  of  the  first  sen- 
ses impaired,  and  it  may  be  lowered  early  in  the  dis- 
ease and  go  rapidly  on  to  blindness  through  atrophy 
of  the  optic  nerve.  As  a  rule,  however,  it  either  does 
not  advance  beyond  a  certain  point,  or  its  progress  is 
very  slow.  Visual  disturbances  occur  (Ross)  in  30 
per  cent,  of  all  cases.  Paralysis  of  the  ocular  muscles 
is  a  common  and  early  sign  of  tabes,  and  it  is  present 
in  such  a  large  percentage  of  cases  that  the  occurrence, 
of  ocular  pareses  (ptosis,  squint,  etc.)  in  an  adult 
should  always  give  rise  to  suspicions  of  this  disease. 


—  125  — 

The  paralysis  is  at  first  partial  and  transitory,  but  as 
the  spinal  degeneration  advances  it  becomes  perman- 
ent and  incurable.  The  patient  complains,  of  course, 
of  double  vision  (136).  If  it  be  affected  at  all  the  pupil 
is  nearly  always  contracted.  In  Eulenburg's  collec- 
tion of  64  cases  of  tabes  28  had  myosis  (95).  But  the 
most  important  eye-sign  of  locomotor  ataxy  is  the 
Argyll- Robertson  pupil;  that  is,  the  pupil  contracts  to- 
accomodation  (95),  but  will  not  contract  to  light  (8). 
Even  when  myosis  is  present  the  small  pupil  becomes 
still  smaller  when  the  patient  directs  his  gaze  from  in- 
finity to  the  near  point. 

DIPHTHERIA. — The  poison  of  this  disease  gives 
rise,  in  a  fair  percentage  of  cases,  to  paralysis  (cyclo- 
plegia),  more  or  less  complete,  of  the  ciliary  muscle. 
The  accommodation  is  inactive,  and  the  pupils  are 
sluggish  and  dilated.  In  fact,  the  condition  is  much 
the  same  as  if  weak  atropine  drops  had  been  instilled. 
If  a  child  presents  himself  complaining  of  sudden 
inability  to  read  or  to  see  close  at  hand,  but  with 
good  vision  in  the  distance,  and  the  use  of  a  mydri- 
atic  is  excluded,  an  examination  will  be  very  likely  to 
disclose  the  fact  that  he  has  had  diphtheria  some  four 
or  six  weeks  previously.  Such  patients  have  a  nasal 
intonation  due  to  paralysis  of  the  soft  palate. 

Prognosis  is  good.  Even  without  treatment — 
which  should  be  directed  towards  the  general  condi- 
tion— the  eye  symptoms  almost  always  slowly  but. 
entirely  disappear.  A  suitable  reading  glass  may  be 
ordered  while  the  paralysis  of  accommodation  lasts. 


—     126    — 

BRIGHT'S  DISEASE.— In  the  various  nephritic 
affections  included  under  this  heading,  vision  is 
rarely  disturbed  until  the  disease  is  well  established. 
The  ocular  lesion  consists  of  a  degenerative  inflam- 
mation of  the  retina,  and  it  is  one  of  the  gravest 
manifestations  of  Bright's  disease.  More  than  one- 
half  of  such  patients  die  within  a  year,  and  many  of 
them  within  a  few  weeks  or  months,  after  their  sight 
is  thus  affected.  Disturbances  of  vision  due  to  this 
deep-seated  inflammation  occur  in  about  25  per  cent, 
of  all  cases  of  albuminuria  with  organic  disease. 

The  prognosis  is,  of  course,  unfavorable,  although 
some  cases,  associated  with  puerperal  albuminuria 
and  with  scarlatina,  get  well.  In  these  instances, 
however,  it  happens  that  perfect  vision  is  never  recov- 
ered, because  irreparable  damage  has  meantime  been 
done  to  the  percipient  elements  of  the  retina  or  to 
some  of  the  optic  nerve  fibres. 

MIGRAINE,  megrim,  or  sick  headache,  is  frequently 
accompanied  by  temporary  disorders  of  sight.  Either 
before  or  during  an  attack  of  this  distressing  form  of 
neuralgia  a  peculiarly  shaped  cloud  appears  directly 
in  front  of  the  eyes.  It  begins  as  a  dark,  central 
scotoma  having  a  bright  colored  margin,  serrated 
like  a  line  of  fortification,  and  called,  for  this  reason, 
"bastion  scotoma."  This  spreads  until  the  whole 
field  of  vision  is  obscured,  and  lasts  but  a  short  time, 
after  which  sight  is  as  perfect  as  before  the  attack. 
Often  persons  suffering  from  sick  headache  notice 


—  127  — 

muscae  (117)  and  fogginess  only,  instead  of  the  well 
defined  scotoma  just  described.  It  has  also  been  ob- 
served that  persons  subject  to  migraine  always  have 
refractive  errors  (R.  50). 

Prognosis  is  favorable. 

Treatment  will  be  directed  to  the  cause  of  the 
headache.  Amyl  nitrite  (Noyes),  in  from  3-  to  5- 
minim  doses,  will  relieve  the  severe  and  prolonged 
attacks.  Attention  should  be  paid  to  the  refractive 
condition  of  the  eye,  and  when  ametropia  (C.  21)  is 
present  proper  correcting  glasses  should  be  prescribed. 

MALARIA  has  been  blamed  for  many  forms  of 
ophthalmic  disease,  such  as  chronic  conjunctivitis, 
keratitis,  etc.;  but  beyond  finding  circumcorneal  in- 
fection (83)  and  a  few  cases  of  iritis,  I  cannot  honest- 
ly say  that  I  have  seen  many  ocular  affections  of  well- 
defined  malarial  origin.  When  such  do  occur,  the 
treatment  by  anti-periodics  is  not  so  successful  as  in 
other  forms  of  malaria. 

REFLEX  NEUROSES. — Roosa  (50)  has  spoken  of 
the  many  nervous  affections  that  directly  result  from 
defects  of  accommodation  and  errors  of  refraction, 
and  has  shown  how  frequently  the  oculist  is  called 
upon  to  treat  nervous  disorders  having  their  origin  in 
optical  deficiencies.  In  addition  to  these  disturbances 
of  vision  and  of  the  ocular  circulation,  actual  inflam- 
mation of  the  conjunctiva,  iris,  etc.,  are  produced  by 
sympathy  with  diseased  organs  more  or  less  distant 
from  the  eye.  Nasal  diseases  are  among  these.  We 


—    128    — 

have  already  seen  (50)  how  they  may  extend  along 
the  nasal  duct  to  the  lachrymal  andconjunctival  sacs. 
But  in  addition  to  this,  pain  in  the  eye,  conjunctival 
and  ciliary  hypersemia,  epiphora  (49),  and  occasional 
dimness  of  vision  may  be  produced  as  purely  reflex 
phenomena  from  such  nasal  troubles  as  stenosis  from 
ecchondroses,  hypertrophies,  polypi,  bony  spines  on  the 
septum,  empyaema  of  the  maxillary  sinus,  and  so  on.* 

Much  the  same  train  of  symptoms  has  resulted 
from  decayed  teeth.  Uterine  diseases,  as  well  as  venereal 
excesses,  are  sometimes  the  sources  of  similar  symp- 
toms. 

SYMPATHETIC  OPHTHALMIA.  By  this  term  we 
mean  the  involvement  of  an  eye  by  disease  which  has 
spread  from  the  other  eye  by  way  of  the  optic  nerve. 
The  first  ("exciter"),  or  -'exciting"  eye  is,  almost 
without  exception,  an  injured  eye,  and  the  second 
("sympathizer"),  or  "sympathizing  "  eye,  becomes, 
with  almost  equal  uniformity,  the  subject  of  an  irido- 
choroiditis  or  of  an  inflammation  of  the  whole  uveal 
tract — iris,  choroid,  and  ciliary  body.  The  most  dan- 
gerous wounds,  so  far  as  concerns  the  liability  to  sym- 
pathetic ophthalmitis,  are  those  that  penetrate  the 
region  (which  Nettleship  calls  the  "dangerous  zone  ") 
corresponding  to  the  ciliary  body.  This  area,  4  or  5 
mm.  in  width,  extends  around  and  a  few  millimetres 
outside  of  the  sclero-corneal  junction.  Foreign 

*See  Boerne  Bettman's  article,  Journal  American  Med- 
ical Association,  May  7,  1887. 


— •  129  — 

bodies  lodged  in  the  interior  of  the  bulb,  as  well  as 
perforating  ulcers  of  the  cornea,  may  also  light  up  the 
disease. 

Deutschmann  and  Gifford  have  demonstrated  to 
a  certainty  the  fact  that  germs  from  the  inflamed  and 
"exciting"  eye  are  carried  along  the  optic  nerve  to 
the  chiasma,  and  thence  to  the  uveal  tract  of  the 
sound  eye,  where  they  set  up  an  inflammation  of  a 
sero-plastic  type.  From  these  circumstances  the 
disease  has  been  called  ophthalmia  migratoria. 

SYMPATHETIC  IRRITATION. — This  may  be  a  pre- 
monitory stage  of  the  succeeding  ophthalmitis,  or  it 
may  not  proceed  further.  The  chief  sign  of  it  is 
tenderness  on  pressure  over  the  ciliary  region — the 
patient  draws  his  head  away  when  the  eye  is  pressed 
upon  (9).  There  is  also  slight  photophobia,  and 
some  ciliary  injection.  Usually  there  is  no  pain 
whatever.  The  stealthy  setting  in  of  these  symp- 
toms on  the  sound  side,  after  a  penetrating  wound  of 
the  other  eye,  may  well  cause  the  surgeon  some  anx- 
iety. He  should  be  on  the  lookout  for  them  at  almost 
any  date  subsequent  to  three  weeks  after  such  a  trau- 
matic lesion.  Sympathetic  ophthalmia  has,  indeed, 
been  observed  as  early  as  two  weeks  and  as  late  as  20 
years  after  injuries.  In  other  words,  an  eye  contain- 
ing a  foreign  body,  or  one  which  has  been  the  subject 
of  traumatic  cyclitis,  is  a  dangerous  eye,  and  liable  at 
any  time  to  bring  ruin  upon  itself  or  its  fellow  organ. 

After  the  slight  warnings  just  spoken  of,  definite 

9  zz 


changes  show  themselves  in  the  sympathizing  eye. 
To  the  tenderness  are  added  occasional  slight  pains, 
more  photophobia  and  more  lachrymation,  while  vision 
becomes  sensibly  impaired.  One  soon  notices,  be- 
sides the  pericorneal  injection,  a  serous  iritis  with  ker- 
atitis  punctata  (69)  and  a  deep  anterior  chamber  (7). 
Then  plastic  deposits  take  place  in  the  ciliary  body, 
the  vitreous  becomes  cloudy,  cataract  invades  the  lens, 
the  nutrition  of  the  whole  eye  is  interfered  with,  and 
after  a  longer  or  shorter  period  of  suffering  marked, 
it  may  be,  by  teasing  pains  in  the  eye,  atrophy  of  the 
bulb  (phthisis  bulbi)  results  with  total  loss  of  vision. 
If  relief  is  given,  the  -eye  may  partially  or  wholly 
recover;  but,  whether  it  does  or  not,  the  course  of  the 
disease  is  always  very  chronic,  very  wearisome  and 
very  variable.  It  may,  in  fact,  happen  that  months, 
or  even  years,  after  an  attack  of  sympathetic  inflam- 
mation, the  injured  eye  has  better  vision  than  its 
fellow. 

Treatment. — The  treatment  of  migratory  ophthal- 
mia requires  special  care  and  special  knowledge. 
The  conduct  of  a  case  in  which  signs  of  this  dreaded 
disease  appear  should  not  be  lightly  undertaken  by  a 
non-specialist.  The  most  important  rules  for  him  to 
remember  are  those  which  refer  to  the  removal  of  the 
"exciting"  eye.  When  an  eye  is  so  injured  that  no 
useful  vision  remains  or  none  can  be  preserved,  it 
should  be  enucleated  (132).  When  this  is  not  done 
the  case  ought  to  be  constantly  watched  until  the 


injured  eye  has  entirely  healed  and  becomes  "  quiet," 
-or  until  symptoms  of  "sympathy"  show  themselves  in 
-the  other  eye.  An  attempt  should  be  made  to  secure 
the  former  result  by  bringing  the  edges  of  the  wound 
into  apposition.  Sutures  may  be  applied  if  in  the 
sclera.  Prolapsed  iris  and  vitreous  must  be  cut  off 
with  the  scissors  and  the  stump  of  the  former 
replaced  (95).  Blood  clots  must  be  removed,  the 
•conjunctival  sac  thoroughly  irrigated  and  the  eye 
carefully  disinfected  (31);  in  fact,  the  wound  and  its 
surroundings  must  be  made  and  kept  as  surgically 
clean  as  possible.  The  dressings  (antiseptic  gauze  is 
the  best)  should  be  changed  frequently,  if  there  be 
any  discharge  or  pain.  This  line  of  treatment  must 
be  persevered  in  until  healing  has  taken  place. 

In  the  event  of  sympathetic  symptoms  appearing, 
and  vision  is  fairly  good  in  the  injured  eye,  the  prob- 
lem of  treatment  is  such  a  difficult  one  that  want  of 
space  prohibits  its  discussion  here.  In  addition  to 
the  hints  already  thrown  out  I  would  refer  the  reader 
to  the  excellent  rules  laid  down  by  Swanzy  (Diseases 
of  the  Eye,  p.  230).  When  the  practitioner  or  his  pa- 
tient cannot  obtain  competent  advice  during  the  vary- 
ing phases  of  this  troublesome  affection  it  is  best  to 
.sacrifice  the  injured  eye,  even  when  its  vision  is  fair, 
•on  the  first  approach  of  sympathetic  "  irritation,"  that, 
happily,  further  advance  of  the  disease  may  be  stayed. 
At  the  same  time  it  is  right  to  remember,  and  wise  to 
warn  the  patient,  that  even  after  the  exciting  eye  has 


been  excised  two  weeks  must  pass  before  one  can  feel 
certain  that  ophthalmitis  may  not  develop  in  the 
sound  eye.  In  other  words  morbific  germs  from  the 
injured  eye  may  have  been  on  their  way  to  or  have 
already  reached  the  other  eye  before  the  exciting  eye 
was  removed 

When  ophthalmia  migratoria  has  set  in  and  the 
vision  in  the  injured  eye  is  fairly  good  the  usual  plan 
among  oculists  is  not  to  excise  the  offending  organ 
(in  a  person  who  can  wait)  but  to  fight  the  disease 
with  appropriate  remedies,  because,  as  before  stated, 
it  may  happen  that,  after  months  of  patient  nursing, 
vision  in  the  exciting  eye  is  better  than  that  of  the 
uninjured  eye. 

ENUCLEATION  or  excision  of  the  eye  is  usually 
performed  with  a  strong  pair  of  scissors  (Fig.  30), 
curved  on  the  flat,  a  pair  of  fixation  forceps  (Fig.  16) 
and  a  strabismus  hook  (Fig.  32).  A  strong  solution  of 


FIG.  30. 

cocaine  is  relied  upon  by  some  operators  as  an  an- 
aesthetic. It  is  applied  to  the  cornea  and  injected  be- 
hind the  bulb  as  soon  as  the  capsule  of  Tenon  (144) 
is  opened,  but  when  the  eye  is  inflamed  very  little 
of  the  solution  is  absorbed  and  then  it  is  best  to  give 


—   133  — 

ether  or  chloroform.  A  speculum  is  introduced  and 
the  eye  being  fixed  the  conjunctiva  is  cut  through 
with  the  scissors  all  round  the  cornea.  Each  rectus 
tendon  is  now  severed  on  a  strabismus  hook  close 
to  the  globe.  Now  separate  the  branches  of  the 
speculum  and  the  eyeball  will  start  forward.  Space 
is  given,  in  this  way,  to  cut  carefully  through  the  re- 
maining muscles,  faschia,  and  other  attachments,  al- 
ways keeping  close  to  the  globe.  Last  of  all  the  optic 
nerve  is  divided  and  the  eyeball  comes  away. 
Haemorrhage  may  be  free  but  it  is  readily  controlled 
by  plugging  the  orbit.  The  conjunctiva  is  left  to  it- 
self; a  simple  boracic  lotion  is  used  to  bathe  the  parts 
and,  in  most  cases,  simple  gauze  dressing  applied 
over  the  lids  is  all  that  is  required.  In  from  3  to  6 
weeks  time,  when  all  irritation  and  discharge  have 
-subsided,  an  artificial  eye  may  be  worn. 


LESSON  X. 

PARALYSIS,    SQUINT    AND    OTHER    MUSCULAR 
TROUBLES. 

The  Physiology  of  the  Subject — The  Nerve  Supply — Ocular 
Paralyses — Their  Symptoms — Paralysis  of  the  Sixth 
Nerve — Paralysis  of  the  Fourth  Nerve— Oculo-motor 
Paralysis — Ophthalmoplegia — Causes  and  Treatment 
of  Paralysis — Strabismus  or  Squint — Convergent  and 
Divergent  Squint — The  Measurement  of  Squint — Treat- 
ment— Operations  for  Strabismus  —  Tenotomy — Ad- 
vancement. 

The  centre  about  which  the  eyeball  rotates  is 
situated  in  the  line  of  its  visual  axis  about  14  mm. 
behind  the  cornea.  Three  pairs  of  mitscles  move  it 
in  various  directions.  The  separate  action  of  the 
rectus  externus  is  to  rotate  the  eye  outwards,  of  the 
rectus  internus  to  move  it  inwards,  while  more  com- 
plicated movements  in  various  directions  are  effected 
by  the  combined  action  of  these  with  the  superior  and 
inferior  oblique  muscles.  The  fourth  nerve  supplies 
the  superior  oblique,  the  external  rectus  is  supplied 
by  the  sixth  nerve  while  the  other  ocular  muscles  (in- 
cluding the  levator  palpebra  superioris,  the  sphincter 
pupillse  and  the  ciliary  muscle)  are  under  the  influence 
of  the  oculo-motorius-  the  third  cerebral  nerve. 

When  a  person,  with  erect  head,  looks  at  a  distant 
object  directly  in  front  of  him  and  in  the  horizontal 
plane,  head  and  eyeballs  are  said  to  be  in  \.\\Q primary 


position.     This  is  accepted  as  a  sort  of  standard  with 
which  to  compare  all  other  positions  of  the  globe. 

Abnormal  attitudes  of  the  eyeball  are  taken   in      J  +       o 
cases  of  heterophoria — muscular  insufficiencies  -  (R.  45)   " 
(8),  ocular  paralysis  and  strabismus  or  squint. 

Diagnosis.  The  detection  of  insufficiencies  has 
already  been  spoken  of  (n).  When  affected  by 
either  squint  or  paralysis,  both  eyes  are  not  directed 
towards  the  same  quarter  in  all  positions  of  both 
globes.  One  disease  may  easily  be  differentiated 
from  the  other  by  the  simple  expedient  of  testing 
the  excursion  (n)  of  each  eyeball  in  all  directions. 
Examined  separately  they  will  be  found  to  have  a 
normal  excursion  in  squint  while  restricted  movement 
in  one  or  more  directions  can  be  detected  when  a 
muscle  (or  muscles)  is  affected  by  paralysis. 

PARALYSIS  OF  THE  EYE  MUSCLES.  Although  it 
is  usual  to  speak  of  paralysis  of  the  eye  muscles  yet, 
for  clinical  reasons,  it  is  advisable  not  to  forget  their 
nerve  supply  (134).  For,  as  a  matter  of  fact,  it  is  the 
nervous  function  that  is  disturbed  or  abolished,  and  if 
one  recollect  the  ocular  innervation  paralytic  diseases 
of  the  muscles  resolve  themselves  naturally  into  well 
defined  clinical  groups,  as  we  shall  see.  It  is  mainly 
for  purposes  of  diagnosis  — when  one  wishes  to  dis- 
cover what  particular  muscle  or  muscles  are  involved 
— that  prominence  is  given  to  the  loss  of  muscular 
function. 

There  are  certain  symptoms  common  to  all  forms 


of  paralysis.  The  most  important  of  these  is  diplopia 
— the  patient  sees  double.  This  occurs  in  every  in- 
stance where  vision  in  both  eyes  is  good,  and  is  due 
to  the  fact  that  images  of  objects  do  not  fall  on  cor- 
responding parts  of  both  retinae.  It  is  by  the  relation 
of  these  double  images — a  somewhat  difficult  subject 
for  the  student — that  most  authors  seek  to  indicate 
the  particular  muscle  affected.  Giddiness  and  even 
nausea — the  nervous  effects  of  the  diplopia  and  of  the 
false  projection — as  well  as  indistinct  vision  are  symp- 
toms frequently  complained  of.  Headache  is  not  un- 
common. The  patient,  to  avoid  the  annoyance  of 
double  vision,  will  usually  close  one  eye  or  turn  his 
head  towards  the  paralyzed  muscle.  This  sign  often 
indicates  which  muscle  is  affected,  y 

PARALYSIS  OF  THE  EXTERNAL  RECTUS  or  of  the 
sixth  nerve.  This  is  easily  recognized  and  is  proba- 
bly the  commonest  form  of  the  ocular  pareses.  The 
patient  has  double  vision  and  the  other  symptoms 
mentioned,  and  when  the  head  is  in  the  primary  posi- 
tion (134)  the  eyes  converge.  The  diagnosis  between 
this  disease  and  convergent  squint  may  be  easily  made 
by  the  method  just  referred  to  (135). 

PARALYSIS  OF  THE  SUPERIOR  OBLIQUE  or  of  the 
fourth  nerve.  The  ocular  excursion  downwards  and 
inwards  is  defective  in  this  paralysis.  In  the  field 
above  the  horizon  there  is  single  vision  but  below  it 
diplopia.  In  looking  downward  at  the  sidewalk  ob- 
jects are  seen  displaced  and  distorted  so  that  walking 


—  137  — 

is  difficult  or  impossible.  The  lower  limbs  of  people 
assume  a  mixed  and  multiplied  appearance,  while 
their  heads  and  faces  are  natural.  It  is  difficult  to 
measure  accurately  the  height  of  a  step  one  is  about 
to  put  the  foot  upon,  etc.  Much  the  same  symptoms 
are  present  in  those  cases  where  the  inferior  rectus 
alone  is  involved,  y 

OCULO-MOTOR,  or  third  nerve,  paralysis.  Any 
one,  two,  three,  four,  five,  six  or  all  (134)  of  the  mus- 
cles supplied  by  the  third  nerve  may  be  paralyzed. 
Usually,  however,  there  is  ptosis  (45),  from  paralysis 
of  the  levator  palpebrae,  with  mydriasis  and  loss  of 
accommodation  due  to  involvement  of  the  sphincter 
pupillae  and  ciliary  muscle.  The  paralysis  of  other 
muscles  can  be  made  out  by  the  loss  of  motion  proper 
to  each.  It  must  not  be  supposed  that  it  is  always 
easy  or  possible  to  say  just  what  muscle  or  muscles 
are  affected  on  account  of  the  secondary  contractions 
and  deviations  that  occur  in  both  eyes,  owing  to 
efforts  to  obtain  binocular  vision.  r- 

OPHTHALMOPLEGIA  INTERNA  AND  EXTERNA. 
The  former  term  is  applied  to  paralysis  of  the  sphinc- 
ter pupillae  and  ciliary  muscles  when  it  occurs  alone. 
In  the  latter  also  called  from  its  origin,  nuclear  par- 
alysis, all  or  most  of  the  external  muscles  are  affected 
to  the  exclusion  of  the  ciliary  muscle  and  pupillary 
sphincter. 

Causes  of  paralysis  are  chiefly  rheumatic  or  syph- 
ilitic affections,  either  of  the  nerves  themselves  in 


-  138  - 

their  course  from  the  brain,  or  of  their  nuclei.  Organ- 
ic deposits  in  the  bony  canals  along  which  most  of 
the  cerebral  nerves  run,  or  exostoses  from  their  walls, 
as  well  as  growths  from  the  neurilemma,  may  exert 
pressure  sufficient  to  bring  about  a  temporary  aboli- 
tion or  a  total  loss  of  their  function.  The  reabsorp 
tion  of  these  growths  or  deposits  may  result  in  a  cure 
unless  too  great  damage  has  been  done  to  the  nervous 
elements.  Where  one  nerve  alone  is  affected  the 
cause  is  probably  a  peripheral  one,  while  nuclear  par- 
alysis is  to  be  suspected  if  more  than  one  nerve  suf- 
fers. Von  Graefe's  test  must  be  borne  in  mind,  viz. : 
when  fusion  of  the  double  images  by  the  use  of 
prisms  is  easy  the  lesion  is  probably  peripheral,  but 
when  it  is  difficult  to  obtain  and  retain  single  vision 
the  paralysis  is  due  to  spinal  or  cerebral  disease. 
Although  syphilis  and  rheumatism  play  a  very  import- 
ant role  in  the  causation  of  these  pareses  it  is  some- 
times difficult  to  demonstrate  their  presence.  A  few 
cases,  however,  result  uniformly  from  one  cause;  par- 
alysis of  the  external  rectus,  for  example,  almost  in- 
variably occurs  in  rheumatic  subjects.  Diphtheria 
sometimes  produces  orbital  paralysis  and,  as  before 
mentioned  (125)  is  a  cause  of  cycloplegia  with  dilated 
pupil  (iridoplegia).  Reference  has  already  been  made 
to  the  frequency  of  these  paralyses  in  locomotor  ataxia 
(124).  Paralysis  of  the  external  rectus  is  not  unusual 
in  diabetes.  • 

Prognosis.     Diphtheritic  paralysis  and  the  prim- 


—  139  — 

ary  paralysis  of  tabes  almost  invariably  disappear.  So- 
do  most  of  those  that  depend  upon  peripheral  causes. 
If  of  central  origin  many  syphilitic  cases  get  well,  but 
some  do  not.  For  obvious  reasons  the  later  tabetic 
pareses  remain,  as  well  as  many  others  of  central 
origin. 

Treatment.  It  is  justifiable  to  cover  the  affected 
eye  with  a  shield  so  as  to  guard  against  the  troubles 
of  diplopia.  Specific  treatment  will  be  given  when 
it  is  indicated,  and  even  when  there  is  no  definite  his- 
tory of  syphilis  potassic  iodide,  given  in  gradually  in- 
creasing doses  until  30  or  40  grs.  are  taken  three 
times  daily,  may  be  continued  for  several  weeks  or 
months.  Cupping  the  temple  in  the  early  stages  and 
the  employment  of  the  constant  electric  current  are 
remedies  of  extreme  value.  Cocainize  the  eye  and 
place  the  negative  pole  (a  small  sponge)  between  the 
lids  directly  over  the  paralyzed  muscle.  The  positive 
pole  may  be  applied  to  the  neck.  This  can  be  kept 
up  for  three  or  four  minutes  at  a  time  and  is  a  better 
plan  than  the  usual  application  of  a  larger  sponge  to- 
the  closed  lids.  Passive  motion  (Michel)  may  be  ap- 
plied in  this  as  in  other  forms  of  paralysis.  Under 
cocaine  the  insertion  of  the  muscle  is  seized  with  fix- 
ation forceps  and  the  eyeball  drawn  or  pushed  in  the 
direction  of  its  contraction  and  back  again.  This  is 
to  be  done  once  a  day  (or  oftener)  for  a  minute  at  a 
time.  Surgical  interference,  as  in  strabismus  (143), 
may  be  resorted  to  in  long-standing  cases  when  med- 


—   140  — 

ical  measures  have  failed  to  restore  the  lost  muscular 
function. 

STRABISMUS  or  SQUINT.  This  affection  is  some- 
times called  "concomitant"  squint  because  although 
the  relation  of  the  visual  axes  is  not  a  normal  one  it 
is  a  constant  relation — one  eye  moves  about  when  the 
other  does.  In  "paralytic"  squint  this  is  not  the 
case.  Much  confusion  arises  from  the  calling  of  par- 
alytic diseases  "squint"  and  it  would  be  better  to  con- 
fine that  term  to  the  conditions  about  to  be  described. 

The  two  most  important  and  by  far  the  common- 
est varieties  of  this  disease  are  convergent  and  divergent 
strabismus.  In  the  former  case,  when  one  eye  fixes  an 
object  the  other  converges  or  turns  in  more  than  it 
should;  in  the  latter  instance  the  non-fixing  eye  di- 
verges or  turns  out.  Usually  one  eye  does  the  "fix- 
ing" (and  seeing)  while  the  other  squints.  This  is 
called  constant  or  unilateral  strabismus.  Sometimes 
(and  then  both  eyes  have  the  same  visual  acuity)  it 
seems  to  be  a  matter  of  indifference  to  the  patient 
with  which  eye  he  fixes  and  which  eye  squints;  some- 
times it  is  one,  sometimes  the  other.  These  form  an 
important  class  of  alternating  squints.  Other  cases 
squint  occasionally  only — the  so-called/<r/vW/V  squint. 

It  is  easy  enough  to  detect  squint  if  the  eye- 
covering  test  (n)  be  applied,  but  o  ;art  from  tests 
most  squinting  eyes  manifest  themselves  if  the  patient 
be  directed  to  look  first  at  a  near  point — say  30  cm. 
in  front  of  his  nose — and  then  at  some  distant  object 


Causes. — The  causation  qf  squint  is  wrapped  in 
mystery  notwithstanding  all  the  investigations  of  the 
subject  and  all  that  has  been  written  about  it.  Some 
very  pretty  theories  have  been  advanced  to  explain 
all  the  facts,  but  none  has  yet  done  so  satisfactorily. 
It  may  be  said,  speaking  in  general  terms,  that  while 
the  optical  centres  of  most  (not  all)  individuals  prefer 
binocular  vision  they  insist  upon  clear  images  of  ob- 
jects. So  that,  if  one  optic  nerve  receives  and  con- 
veys to  the  cerebral  centres  the  sensation  of  a  blurred 
image  and  the  other,  at  the  same  time,  transmits  a 
clear  or  clearer  image  the  fiat  goes  forth  to  suppress 
the  less  distinct  image.  This  is  done  by  sacrificing 
binocular  vision,  making  the  eye  turn  in  or  out  ac- 
cording as  convergent  or  divergent  power  predomin- 
ates. Now,  the  interni  muscles  being  strongest  in 
hypermetropes  and  emmetropes  we  find  that  these 
persons  are  almost  always  subject  to  convergent 
squint.  Myopes,  on  the  other  hand,  have  relatively 
strong  externi  and  weak  interni;  hence  the  strabismus 
in  myopia  is  of  the  divergent  kind. 

Strange  to  say  there  is  no  double  vision  in  strab- 
ismus, since  the  brain  suppresses  the  indistinct  image 
of  the  squinting  eye — just  as  when  "  in  a  brown 
study "  one's  retina  does  not  perceive  surrounding 
objects. 

Convergent  strabismus  usually  sets  in  between 
the  ages  of  one  and  five  when  the  child  has  begun  to 
use  its  interni  muscles  for  convergence.  The  great 


—   142  — 

majority  of  us  are  born  hypermetropic  (R.  36)  and  that 
is,  perhaps,  the  reason  why  most  squinting  children 
are  affected  by  convergent  squint.  Divergent  strab- 
ismus, on  the  other  hand,  is  less  frequent  in  this 
country  owing  to  the  comparative  rarity  of  myopia. 
Short-sightedness  is  a  disease  of  adolescence;  hence 
divergent  squint  develops  later  in  life  than  the  con- 
vergent variety. 


FIG.  31. 

The  degree  of  squint  is  measured  by  the  strabo- 
meter  and  other  instruments.  The  former  is  pictured 
in  Fig.  31.  The  patient  is  in  the  primary  position  (134) 
and  the  instrument  is  placed  along  the  lower  orbital 
margin  of  the  squinting  eye.  The  centre  of  the  pupil 
will  now  be  found  opposite  a  number  which  indicates 
in  lines  (or  millimetres)  the  amount  of  deviation. 
This  must  be  done  both  for  near  and  distant  fixation. 

Treatment. — The  patient  must,  first  of  all,  be 
given  full  correction  of  all  refractive  errors.  Weak 
atropine  drops  are  also  prescribed  for  a  few  weeks 
and  the  glasses  worn  constantly.  In  a  fair  percentage 
of  hypermetropic  cases  this  alone  will  bring  about  a 
•complete  cure  in  the  course  of  several  months  or  a 


—   143  — 

year.  If,  after  this  trial,  little  or  no  improvement  re- 
sults an  operation  is  indicated. 

Assuming  that  glasses  are  worn  and  atropine 
used,  the  following  rough  rules  will  serve  to  indicate 
the  date,  the  amount  and  the  kind  of  operative  inter- 
ference necessary:  i.  If  possible  the  operation 
should  be  done  on  the  squinting  eye.  2.  Use  cocaine 
for  tenotomies  and  chloroform  for  advancements.  3. 
The  more  the  tendon  is  loosened  from  its  connective 
tissue  bed  the  greater  the  effect  of  the  tenotomy.  4. 
In  convergent  squint,  where  the  strabismus  is  not  more 
than  one  line,  a  free  tenotomy  of  one  internal  rectus 
may  be  sufficient.  When  the  deviation  amounts 
to  two  lines  both  interni  should  be  divided.  More 
than  that  calls  for  section  of  one  internus  with  ad- 
vancement of  the  externus  of  the  same  eye.  5.  Slight 
degrees  of  divergent  squint  call  for  a  tenotomy  of  the 
external  rectus.  Marked  deviations  will  need,  in  ad- 
dition, advancement  of  the  internus  muscle.  6. 
When  the  squinting  eye  is  amblyopic  (119)  or  when 
from  other  causes,  such  as  corneal  opacities,  cataract, 
etc.,  its  vision  is  but  slightly  or  not  at  all  improved  by 
glasses,  the  spectacle  and  atropine  treatment  exerts 
no  influence  upon  the  squint  and  for  the  sake  of  ap- 
pearances (cosmetic  effect)  the  operation  should  be 
proceded  with  at  once. 

Tenotomy  of  a  muscle  is  done  in  the  following 
fashion:  The  eye  having  been  well  cocainized,  is 
rolled  over  by  fixation  forceps  (Fig.  14)  to  the  side 


—   144  — 

opposite  to  that  on  which  the  operation  is  to  be  done, 
and  is  retained  in  position  by  the  assistant.  The 
conjunctiva  and  sub-conjunctival  tissue  immediately 
over  the  tendinous  insertion  are  caught  up  by  another 
pair  of  forceps,  and  a  fold  of  mucous  membrane  cut 
through  by  a  pair  of  straight  scissors  at  the  lower 
edge  of  the  tendon.  The  points  of  the  scissors  are 
now  passed  into  the  aperture,  Tenon's  capsule  is 
opened,  and  the  tissues  lying  over  and  on  both  sides 
of  the  muscle  are  undermined  as  much  as  necessary. 
Next,  the  strabismus  hook  (Fig.  32)  is  slipped  into 


FIG.  32. 

the  opening,  and  with  a  half  turn  is  made  to  pass 
under  the  tendon.  This  last  manceuver  requires  some 
practice.  Be  sure  that  the  hook  point  is  applied  to 
the  globe,  and  that  it  is  far  enough  back  before 
rotating  its  point  underneath  the  muscle.  On  draw- 
ing it  forward  there  should  be  a  feeling  of  resistance, 
and  one  should  make  certain  that  the  point  presents 
free  of  all  the  tissues  on  the  other  side  of  the  muscle. 
Now  divide  the  tendon,  put  somewhat  on  the  stretch, 
between  the  hook  and  the  eyeball,  as  close  to  the 
latter  as  possible.  The  hook  will  give  way  and  come 
forward  to  the  corneal  margin,  showing  that  the  ten- 
don, and  not  merely  some  connective  tissue  fibres, 


—  145  — 

have  been  severed.  With  the  curve  of  the  hook 
sweep  round  on  both  sides  of  the  cut  tendon  so  as  to 
catch  up  and  divide  all  remaining  fibres.  If  the  con- 
junctival  opening  is  small  no  suture  is  necessary. 

Advancement  of  a  muscle  is  done  under  ether 
or  chloroform.  There  are  many  methods,  but  that  of 
Schweigger  has  my  preference.  The  conjunctiva  is 
well  divided  over  the  muscle,  the  latter  being 
thoroughly  exposed  and  well  cleaned  of  connective 
tissue.  The  mucous  membrane  is  now  extensively 
undermined  on  all  sides,  quite  up  to  the  corneal  mar- 
gin and  along  one-third  of  its  circumference.  Two 
strabismus  hooks  are  passed  underneath  the  muscle 
(one  from  each  side),  or  an  advancement  forceps 
(Prince's  is  best :  see  Fig.  33)  is  made  to  grasp  the 


FIG.  33. 

muscular  body  so  as  to  hold  it  steady  and  away  from 
its  bed.  A  double-needled  piece  of  catgut  is  passed 
through  the  centre  of  the  muscle  and  is  tied  firmly  at 
its  edge  below.  The  same  thing  is  done  above.  The 
muscle  is  next  cut  off  close  to  the  sutures  on  its  bul- 
bar  side,  and  the  needles  of  each  suture  are  directed 
underneath  and  through  the  undermined  conjunctiva 
(two  above  and  two  below)  well  forward  and  close  to 
the  cornea.  The  muscle  may  now  be  drawn  towards 


—  146  — 

the  corneal  margin  until  the  eyeball  is  made  to  assume 
the  desired  position.  Each  half  suture  is  now  tied  to 
its  fellow  over  the  intervening  conjunctiva.  The 
original  opening  in  the  mucous  membrane  is  stitched 
together  by  fine  sutures.  There  may  be  some  re- 
action following  this  operation  requiring  the  frequent 
application  of  hot  fomentations,  but  if  proper  precau- 
tions (31)  have  been  taken  this  is  unusual. 


INDEX. 

The  student  is  advised  to  read  over  the  Index 
carefully,  looking  up  the  references  to  those  subjects 
with  which  he  is  not  familiar. 


A.  PAGE. 

Abscess  of  cornea , 68 

lachrymal 51 

orbital 121 

Acuity,  visual 12 

tests  of 13 

Acid  boric,  use  of 26 

Advancement  of  ocular  muscles 145 

Albinism 79 

Alcoholic  amblyopia 120 

Amblyopia 119 

toxic 119 

Anel's  syringe 54 

Arcus  senilis 56 

Aphatia .  .  98 

Astigmatism 74,  75 

Atrophy  of  optic  nerve 95 

Atropine. .  .*. 22,  89 

irritation 32 

B. 

Bandages  for  eye 29 

Basedow's  disease 123 

"  Black  eye  " 36 

Blepharitis  marginalis 34,  50,  102 


—  148  — 

PAGE. 

Blood-vessels,  anterior  ciliary 10 

of  conjunctiva 6 

episcleral n,  83,  114 

Bowman's  probes 53,  55 

Bright's  disease,  eye  symptoms  in 126 

C. 

Calomel  in  eye  diseases  27 

Canaliculi 4 

Canaliculus,  slitting  of 52 

Canthoplasty 41 

Cartilage,  tarsal,  or  tarsus 6 

Caruncle 4 

Cataract,  varieties  of 97,  99,   109,  no 

operations  for 105,  108,  no 

Cautery  applications 31,  72 

Chalazion  or  tarsal  cyst 38 

Chamber,  anterior 7,  114 

Cilia,  normal 4 

forceps 35,  42 

Cocaine,  action  and  use  of 24 

Color  perception,  test  of 14,  120 

Coloboma  of  iris 79 

Conjunctiva,  normal 5 

Copper,  sulphate  of 27 

Coquilles 30 

Cornea,  abscess  of 68 

foreign  bodies  in 65 

normal 7 

speed 66,  73 

tattooing  the 77 

ulcers  of 57,  59,  69 

Cycloplegia 138 

Cystotome 104 


—  149  — 

D.  PAGE. 

Dacryocystitis .- 49 

Diplopia 136 

Diphtheria,  eye  signs  in 95,   125,  138 

Discs,  use  of  ophthalmic 26 

Discission  for  cataract ...  no,  in 

needle no 

Dislocation  of  lens 97 

Distichiasis 40 

Duboisia,  action  of 23,  89 

E. 

Ecchymosis  of  lids 36 

Ectropion 44 

Entropion 40 

Holz's  operation  for 42 

Enucleation  of  eyeball 77,  132 

Epilation 42 

Epiphora 49 

causes  of . . . . : 49 

Episcleritis 77 

Eserine,  action  of 23,  116 

Evisceration  of  globular  contents 77 

Excursion  of  eyeball 1 1,  135 

Eye,  inspection  of  normal 3 

"  strain" 36,  39 

Eyes  of  children,  examining 14 

examination  of  diseased  1 6 

Eyelids,  normal 4 

F. 

Facets  of  cornea 74 

Forceps,  cilia 42 

fixation 92 

iris 94 

Foreign  bodies  in  cornea 65 


G.  PAGE. 

Glands,  meibomian 5 

Glaucoma 95,  112 

Goggles  and  coquilles 30 

Goitre,  exophthalmic 122 

Graefe's  cataract  knife 92 

Graves'  disease 125 

H. 

Herpes  of  cornea 37,  74 

lids 37 

Heterophoria 135 

Heterophthalmos 79 

Hippus 96 

Homatropine,  action  of 23,  98 

Hordeolum    37 

Holz's  operation  for  entropion 42 

Humor,  aqueous 7 

Hyalitis 118 

Hyphcema 80 

Hypopyon 71 

I. 

Inspection  of  normal  eye 3 

Iridectomy 77,  91,  115 

optical 93,  no 

Iridodialysis 80 

Iridodonesis 97 

Iridoplegia 138 

Iris,  normal .% 7,  82 

coloboma  of 79 

forceps 94 

repositor 95 

scissors 94 

Iritis,  various  forms  of So,  89,  91,  108,  127,  130 

recurrent 94 


K.  PAGE. 

Keratitis 56 

interstitial. 66 

parenchymatous 66 

phlyctenular • 57 

punctate 69,  130 

Keratome 92,  93 

L. 

Lachrymal  abscess 51 

probes 53 

sac 5 

Lagophthalmos 47 

Lapis  divinus 28 

Lead  acetate,  use  of 28 

Lens,  absence  of 98 

crystalline 97 

dislocation  of 97,  112 

Leucoma 75 

adherens 72 

Lids,  ecchymosis  of 36 

examination  of 5 

Lithiasis,   meibomian 34 

Locomotor  ataxia 124 

If. 

Macula  of  cornea 75 

Malarial  affections  of  eye 127 

Meyer's  syringe 54 

Migraine,  eye  affections  in 126 

Migratory  ophthalmia 130 

Mucocele 51,  102 

Muscae  volitantes 117,  127 

Muscles,  action  of  ocular 134 

enervation  of 134 

equilibrium  of n 

paralysis  of  ocular 135 


—  152  — 

N.  PAGE 

Nebula  of  cornea 75 

Needling  for  cataract , .  no,  in 

Nystagmus 80,  96 

O. 

Oblique  illumination 9, 

Onyx 71 

Opacities  of  cornea 75,  102 

Operations,  preparing  for 31 

Orbital  abscess 121 

Ophthalmoplegia  137 

P. 

Pagenstecher's  ojntment 26 

Paracentesis  corneae 73 

Paralysis  of  external  rectus 136 

third  nerve 95 

Phlyctenular  keratitis 57 

Photophobia 64,  67,  81,  86 

Phthisis  bulbi 130 

Pilocarpine,  use  of r 25 

Pinguecula 33 

Polyopia 100 

Primary  position 134 

Probes,  lachrymal 53 

Projection  of  light 103 

Pterygium 33 

Ptos  s 45 

Puncta , 4. 

Punctum,  eyelash  in 38 

Pupils,  normal 8 

Pupillary  reaction & 


R.  PAGE. 

"  Red  reflex" 20,  101,  118 

Reflex  symptoms  in  eye  diseases 127 

Rodent  ulcer 40 

S. 

Saemisch's  section 73 

"  Salmon  patch" 67 

Schlemm,  canal  of 8,  112,  115 

Scissors,  enucleation 132 

iris 94 

Sclera  or  sclerotic  coat 7 

Scleritis 77 

Sclerotomy 115 

Scotoma 121,  126 

Shades  for  the  eye 30 

Silver  nitrate,  use  of 28 

Skin,  palpebral.. 4 

Snellen's  lid-clamp 39 

Speculum  for  lids 92 

Speed,  corneal 66,  73 

Staphyloma  anterius 74,  76 

Stenopaic  glasses 80 

Squint,  varieties  of 135,  140,  143 

Strabismus  or  squint 135,  140,  143 

hook 144 

Strabomoter 143 

Stye 37 

Symblepharon 48 

Sympathetic  ophthalmia 128 

irritation 129,  131 

Synechia  anterior 72 

posterior 87,  88,  112 


T.  PAGE. 

Tabes  dorsalis 124 

Tarsoraphy 47 

Tatooing  the  cornea 77 

Tenotomy  of  ocular  muscles 143 

Tension  of  globe 9,   113,  114 

Testing  drum 104 

Test  types  of  Jager  and  Snellen. 13 

Tobacco  amblyopia 119 

Trichcheasis.  . . 40 

U. 

Ulcer  of  cornea 57,  59,  69,  74 

V. 

Vitreous  opacities 118 

X. 

Xanthelasma 40 


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PABKE,  DAYIS  <fe  CO., 

DETROIT   and   NEW   YORK. 


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IN    EXPLANATION 


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LDlbulO     LlUldlj. 


We  have  made  a  new  departure  in  the  publication  of  medical  books.  As  yon 
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SERIES  I. 


•Inhalers,  Inhalations  and  Inhalants. 
By  Beverley  Robinson,  M.  D. 

The  Use  of  Electricity  in  the  Removal  of 
Superfluous  Hair  and  the  Treatment  of 
Various  Facial  Blemishes. 

By  Geo.  Henry  Fox,  M.  D. 
New  Medications,  Vol.  I. 

By  Dujardin-Beaumetz,  M.  D. 

New  Medications.  Vol.  II, 

By  Dujardin-Beaumetz,  M.  D. 

The  Modern  Treatment  of  Ear  Diseases. 
By  Samuel  Sexton,  M.  D. 

The  Modern  Treatment  of  Eczema. 
By  Henry  G.  Piffard,  M.  D. 


Antiseptic  Midwifery. 

By  Henry  J.  Garrijfues,  M.  D. 

On  the  Determination  of  the  Necessity  for 
Wearing  Glasses. 

By  D.  B.  St.  John  Roosa,  M.  D. 
The  Physiological, Pathological  and  Ther- 
apeutic Effects  of  Compressed  Air. 

By  Andrew  H .  Smith,  M.  D. 
GranularLids  and  ContagiousOphthalmla. 

By  W.  F.  Mittendorf,  M.  D. 
Practical  Bacteriology. 

By  Thomas  E.  Satterthwaite.  M   D. 
Pregnancy,    Parturition,    the    Puerperal 
State  and  their  Complications. 
By  Paul  F.  Munde\  M.  D. 


SERIES   II. 


The  Diagnosis  and  Treatment  of  Haem- 
orrhoids 

By  Chas.  B.  Kelsey,  M.  D. 
Diseases  of  the  Heart,  Vol.  I. 

By  Dujardin-Benumetz,  M.  D. 
Diseases  of  the  Heart,  Vol.  II. 

By  Uujardin-Beaumetz   M.  D. 
The  Modern  Treatment  of  Diarrhoea  and 
Dysentery. 

By  A.  B.   Palmer.  M.   D. 
Intestinal  Diseases  o<  Children,  Vol.  I. 

By  A.  Jacobi,  M.  D. 
Intestinal  Diseases  of  Children,  Vol.  II. 

»y  A.  Jacobi.  M.  L». 


The  Modern  Treatment  of  Headaches. 
By  Allan  McLane  Hamilton,   M.  D, 

The   Modern   Treatment  of  Pleurisy  and 
Pneumonia. 

By  G.  M.  Garland,  M.  D 
Diseases  of  the  Male  Urethra. 

By  Fessenden  N.  Otis,  M.  D. 
The  Disorders  of  Menstruation. 

By  Edward  W.   Jenks,  M.  D 
The  Infectious  Diseases,  Vol.  I. 

By  Karl  Liebermeister. 

The  Infectious  Diseases,  Vol.  II. 
By  Karl  Liebermeister. 


SERIES   III. 


Abdominal  Surgery. 

By  Hal  C.  Wyman,  M.  D. 

Diseases  of  the  Liver. 

By  Dujardin-Beaumetz,  M.  D. 

Hysteria  and  Epilepsy. 

By  J.  Leonard  Corning,  M.  D. 

Diseases  of  the  Kidney. 

By  Dujardin-Beaumetz,  M.  D. 

The  Theory  and  Practice  o*  the  Ophthal- 
moscope. 

by  J.  Herbert  Claiborne,  Jr.,  M.  D. 

Modern  Treatment  of  Bright's  Disease. 
By  Alfred  L.  Loomis,  M.  D. 


Clinical  Lectures  on  Certain  Diseases  of 
Nervous  System. 

By  Prof.  J.  M.  Charcot,  M.  L>. 
The  Radical  Cure  of  Hernia. 

By  Henry  O.  Marcy,  A.  M.,  M.  D., 

L.  L.  D. 
Spinal  Irritation, 

By  William  A.  Hammond,  M.  D. 
Dyspepsia. 

By  Frank  Woodbury,  M.  D. 
The  Treatment  of  the  Morphia  Habit. 

By  Erlenmeyer 

The  Etiology,  Diagnosis  and  Therapy  of 
Tuberculosis 

By  Prof.  H.  von  Ziemssen.  . 


SERIES   IV. 


Nervous  Syphilis. 

By  H.  C.  Wood,  M.  D. 
Education  and   Culture  as  correlated  to 
the  Health  and  Diseases  of  Women. 

By  A.  J.  C.  Skene,  M.  D. 


„_,  A.  H.  Smith,  M   D. 
A  Treatise  on  Fractures. 

By  Armand  Despres,  M.  D. 
Some  Major  and  Minor  Fallacies  concern- 
ing Syphilis. 

By  E.  L.  Keyes,  M  .D. 
Hypodermic  Medication. 

By  Bourneville  and  Bricon. 


Practical    Points   in  the  Management  of 
Diseases  of  Children. 
By  I.  N.  Love,  M.  D. 

Neuralgia. 

By  E.  P.  Hurd,  M.  D. 

Rheumatism  and  Gout. 

By  F.  Le  Roy  Satterlee,  M.  D. 
Electricity,  Its  Application  in  Med'cme. 

By  Wellington  Adams,  M .  D.     [Vol.  I] 
Electricity,  Its  Application  In  Medic  ne. 

By  Wellington  Adams,  M.D.  [Vol.IIJ 
Auscultation  and  Percussion. 

Hy  Frederick  C.  Shattuck,  M.  D. 


SERIES    17. 


Taking  Cold. 

By  F.  VV.  Bosworth,  M.  D. 

Practical  Notes  on  Urinary  Analy- 
sis. 

By  William  B.  Canfield,  M.  D. 

Practical  Intestinal  Surgery.  Vol.1. 
Practical  Intestinal  Surgery.  Vol. II- 

By  F.  B.  Robinson,  M.   D. 
Lectures  on  Tumors. 

By  John  B.  Hamilton,  M.  D.,  LL.  D. 

Pulmonary  Consumption,   a   Ner- 
vous Disease. 

By  Thomas  J.  Mays,  M.D. 

Lessons     In     the     Diagnosis    and 
Treatment  of  Eye  Diseases. 

By  Casey  A.  Wood,  M.  D. 


Diseases  of  the  Bladder  and  Pros- 
tate. 

By  Hal  C.  Wyman,  M.  D. 

Artificial  Aneesthesla  and  Anaes- 
thetics. 

By  DeForest  Willard,  M.  D.,  and  Dr. 
Lewis  H.  Adler,  Jr. 

Cancer. 

By  Daniel  Lewis,  M.  D. 

The  Modern  Treatment  of  Hip  Dis- 
ease. 

By  Charles  F.  Stillman,  M.  D. 

Insomnia  and  Hypnotics. 

By  Germain  Se6. 

Translated  by  E.  P.  Kurd,  M.  D. 


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